Skip to main content

Full text of "North Carolina medical journal [serial]"

^ 



Cfie Lftitatp 
Oniticwftp of Ji3ott{) Carolina 




(EnDotoett tip '3E6e Maltctic 

anD 

G>lO B 

ia4o 



KA<zxl.hb 



This book must not 

be taken from the 

Library building 







M £ 17 1 064 



MA¥-mgR — 



ili^' 



UUNGIBM F 40 



m 



North Carolina Library 
MeiiT=?.l r.ibrary 
Chapel Hill, N C 



NORTH CAROLINA 
MEDICAL JOURNAL 




U N. C. MED. 

JAN 16 1940 

LIBRARY 



Vol. 1 



January 1, 1940 



No.1 



II 



ADVERTISEMENTS 



Januai-y, 1940 




Petrolagar 

Helps to establish and maintain a regular llaliit 
Time of IJowcl Movement. One tal)lefi|><)(>nfiil of 
Petrolagar Plain, taken morning and night, promotes 
the formation of a soft, comfortably passed stool. 

Petrolagar is especially useful in the treatment of 
chronic constipation. It may he taken over an ex- 
tended period of time without increasing the dosage. 

Any of the Five Tvpes of Petrolagar will he sent 
to physicians on retpiest. 



r<'fr.W(i^(ir . . . I.iqitiil nrtrutfitutii 6.) re. iniitt^ijied 
liith O.t Cm. agar in a liieiistruuiit la main- 1110 vc. 



Petrolagar Laboratories, Inc. • [5131 McCorniick Boulevard • Chicago, Illinois 




II 



J. BUREN SiDBURY, M.D. 



January, 1940 



ADVERTISEMENTS 



III 



S TUDIEJ lli THE A VI TA M II OSES . .. 

This page is the first of a series on vitamin deficiencies presented 
by the research division of The Upjohn Company, not merely be- 
cause of the profession's widespread interest in the subject.but also 
because of the service which these reproductions might render 
toward earher recognition of vitamin deficiency states. 

The Cutaneous Manifestations of 
Vitamin A Deficiency 




Ml 


Goosepimple-like papules, occasion- 
ally seen in vitamin A deficiency, 
occur most frequently on thighs and 
arms, but may appear anywhere on 
the skin. More common than the 
acneform eruption. 


Acneform papules of vitamin A defi- 
ciency. Pustulationis rare, but crusts and 
scales may be observed. Dryness of in- 
volved skin precedes both types of lesions. 


> 

L. 


M 



Although the classic manifestations of 
vitamin A deficiency are familiar to every 
physician, many of these represent late stages 
of deprivation. In some cases, cutaneous 
changes may provide an opportunity for earlier 
recognition. These cutaneous changes, when 
fully developed, consist of two distinct types 
of eruptions— a goosepimple-like papule and an 
acneform lesion in which pustulation rarely 
occurs. The absence of perspiration is due to 
atrophy of the sweat glands and keratinizing 
metaplasia of the ducts. The papular 
cornified lesions are due to the keratiniz- 
ation of the sebaceous glands and hair - 

lUPJ 



follicles. In some subjects, accentuation in pig- 
mentation due to an increase in melanin and 
melanin-building pigments is observed. Unlike 
the ocular manifestations of vitamin A defi- 
ciency, the skin lesions respond slowly to spe- 
cific therapy, requiring from 4 to 12 weeks for 
their eradication. 



A two-page insert, presenting full-color 
reproductions of vitamin A deficiency lesions, 
and so organized that it may be easily retained 
for future reference, appears in the 
January 20 issue of the Journal of the 
American Medical Association. 



OHNl 



IV 



CONTENTS 



January, 1940 



North Carolina Medical Journal 

Official Organ of 
The Medical Society of the State of North Carolina 



Volume 1 

NUMBEB 1 



January, 1940 



?3.00 A YEAR 
80 CENTS A copy 



CONTENTS 



Original Articles 

The Doctor and Socialized Medicine — J. Buren 
Sidbury, M.D. - . - - 1 

Lewis Burgin McBrayer and the State Sana- 
torium— Chas. H. Cocke, M.D. 8 

Pneumoconiosis — D. M. Brumfiel, M.D. - - - 13 

The Various Forms of Encephalitis — Bernard J. 
Alpers, M.D. 18 

Coordination of Public Health and Related 
Agencies— Carl V. Reynolds', M.D. - - - - 24 

Recent Studies in the Care of the Late Gesta- 
tional Toxemias — Boyd Harden, M.D. - - - 27 

New Urological Procedures of General Surgical 
Interest — Hamilton W. McKay, M.D. - - - 29 

Clinical Experience With Sulfapyridine— W. A. 
MacColl, M.D. ----------- 32 

Some Problems of Diphtheria Control— J. C. 

Knox, M.D. ----- 37 

The Electrocardiogram as an Aid in Cardiac 

Diagnoses- James H. McNeill, M.D. - - - 39 

Editorials 

By Way of Introduction 46 

The NORTH CAROLINA MEDICAL JOUR- 
NAL and the American Medical Association 47 

Greetings— Rock Sleyster. M.D. ----- 47 

A New Member for the Di-stinguished Company 
of State Medical Journals — Morris Fishbein, 

M.D. 47 

Call the Doctor— Nathan B. Van Etten, M.D. 48 

Telegram— Olin West, M.D. 48 

The National Committee for the Extension of 

Medical Service 48 

The Platform of the American Medical Associa- 
tion 49 



Case Reports 

Agranulocytosis — W. M. B. Brown, M.D. - - 50 

Stab Wound of the Heart— A. Hinson, M.D. - 51 

Staphylococcus Meningitis — Robert L. McMil- 
lan, M.D. ------------ 53 

The Bulletin Board 

President's Letter ----------54 

Secretary's Mes'sage 54 

Carolina's New Medical Laboratory and Public 
Health Building - - - 54 

News Notes from Duke University School of 
Medicine -------- 54 

The Bowman Gray School of Medicine of Wake 
Forest College --55 

Medical Society of South Carolina Sesqui-Cen- 
tennial - -55 

North Carolina Pathological Society - - - - 55 

Forsyth County Medical Society ----- 55 

Buncombe County Medical Society - - - - 55 

Caldwell County Medical Society 56 

Warning to Oculists --- 56 

Woman's Auxiliary 

Officers 56 

A Message to the Membership from Its Presi- 
dent 56 

In Memoriam 

Page 56 

Book Reviews 

Page 63 



.Vppliciitlon for entry as second-cln.ss matter at the Post Office In Winalon-Salem is pending. Copyriglit 1010 by the Medical 

Society of the State of North Caioliua. 



North Carolina Medical Journal 

Owned and Published By 
The Mi:di(,ai. Sociirrv of tiik State of Nori'ii Carolina 



Vol. 1 



January, 1940 



No. 1 



THE DOCTOR AND SOCIALIZED MEDICINE^ 



J. BUREN SiDBURY, M.D. 

Wilmington 



Today oui" country enjoys the highest 
standard of medical care in the world. It is 
the earnest desire of the medical profession 
that this high standard not only be main- 
tained but that it be advanced. The task 
before the medical profession is to provide 
adequate medical care at a price which is 
fair to all the people, including those who 
render the service. However, I would like 
to emphasize the point that providing ade- 
quate medical care for all the people, includ- 
ing the indigent, will accomplish very little 
toward the solution of their social and 
economic problems if provision for food, 
shelter, and work to establish a decent 
standard of living is not maintained. 

In his annual report for the United States 
Public Health Service for the year 1938 
Surgeon General Thomas Parran said : "A 
greater advance has been made in public 
health in the United States during the past 
tv\o years than ever before within a com- 
parable period." In this report he states 
that the general death rate for the year 1937 
was 10.9 per 1000 population as compared 
with 11.3 the preceding year. The infant 
mortality rate in 1937 was 54.4 per 1000 
live births as compared with 57.1 for 1936. 
The maternal mortality rate was 4.6 per 
1000 live births for 1937 as compared with 
5.3 in 1936. The infant and maternal death 
rate is a good index to general health condi- 
tions. 

During 1937 lower death rates were re- 
corded for typhoid fever, diphtheria, ma- 
laria, scarlet fever, tuberculosis, nephritis 
and puerpural sepsis. 

F'rom a health .standpoint 1938 was the 
best year in the history of our country ; yet, 

^Presjidenticil address, read before the 86tli annual session of 
the Medical Society of tlie State nf Nortll Carolina, on board 
tlie Queen of Bermuda, May 10, 1939. 



the health reformers in our present federal 
administration declare "the health needs of 
our people can no longer be ignored." They 
would have it appear that the medical pro- 
fession is indifferent to the medical needs 
of the country. 

Approximately 94 per cent of all deaths 
from diseases 50 years ago were from acute 
illness, chiefly infections ; today 75 per cent 
of all deaths occur from chronic illness. 
Three out of four of our deaths from disease 
today are caused by ten diseases. They are, 
in order of rate of mortality, heart disease, 
cancer, pneumonia and influenza, cerebral 
hemorrhage, nephritis, tuberculosis, diabetes, 
diarrhea and enteritis, appendicitis, and 
syphilis. All but three of these are chronic 
diseases. The life expectancy in 1870 was 
40 years and in 1935 the life expectancy was 
60 years. 

In 1900 the average American citizen lost 
28 days per year as the result of illness, 
while in 1938 he lost only 8 days. 

Organized medicine is in accord with the 
objectives of those who advocate socialized 
medicine. It is their proposed method of 
accomplishing this objective that we most 
strenuously object to. Some of these objec- 
tions will be di.scussed in this paper, and a 
fair appraisal of their merits attempted. 
Socialized Medicine Defined 

The term "State Medicine" is a rather 
broad and indefinite one. In order that we 
may more clearly understand what we are 
talking about and what we are objecting to 
in it, a definition is attempted. 

In our State Society we recognize and ac- 
cept a method of treating the mentally sick 
in our State-supported and State-regulated 
institutions. Our State Health Department 
is an institution which we respect and sup- 



NORTH CAROLINA MEDICAL JOURNAL 



Jaiuiary. I'.UO 



poi-t by taxation. The County of New Han- 
over and the City of Wilmington pay to 
James Walker Memorial Hospital $50,000 
annually of tax money to hospitalize the in- 
digent of that county. 

We point with pride to our two State- 
supported Tuberculosis Sanatoria, one at 
Sanatorium and the other at Black Moun- 
tain. We feel that there is none better any- 
where. We know that our Superintendent, 
Dr. P. P. McCain, and his assistant, Dr. S. 
M. Bittinger, have no superiors and we are 
backing them 100 per cent. We believe that 
the management of tuberculosis and the con- 
trol of its spread can be handled best by 
State-supported institutions with the assist- 
ance of private institutions. We are so sold 
on this idea that we are now rejoicing that 
eastern North Carolina is to be the site of 
a third such institution in our State. We 
are in accord with the National Health Pro- 
gram that more hospitals for the treatment 
of tuberculosis should be built. 

In the field of Public Health Education the 
medical profession has realized for a long 
time the value of socialized medicine within 
proper limits. Here may I emphasize that 
the field of treatment to those able to pan 
does not come within this province. 

Then, to what type of Socialized Medicine 
do we object? This can probably best be 
defined by quoting from the House of Dele- 
gates of the American Medical Association 
for the year 1922. "State Medicine is here- 
by defined for the purpo.^^e of this resolution 
to be any form of medical treatment pro- 
vided, conducted, controlled, or subsidized by 
the federal or any State government or 
municipality, excepting such service as is 
provided by the army, navy, or Public 
Health Service and that which is necessary 
for the control of communicable diseases, 
the treatment of mental disea.ses, the treat- 
ment of the indigent sick, and such other 
services as may be approved by and admin- 
istered under the direction of or by a local 
county medical .society and not disapproved 
by the State Medical Society of which it is 
a component part." 

Dr. Peter Irving, Secretary of the Medical 
Society of the State of New York says: 
"When the state endeavors to extend its 
medical activities to the treatment of self- 
supporting patients, threatening to accom- 
pany the doctor across the threshold of the 



sick-room and place the hand of the govern- 
ment upon the patient's pulse, then the doc- 
tor must clearly register his remonstrance." 
The Interdepartmental Committee was ap- 
pointed to study and co-ordinate health and 
welfare activities. From the result of their 
study we were to be advised the best method 
of approach to a .solution of medical caro 
for all the people. The entire personnel ot 
this committee favored socialized medicine 
before they were appointed to the com- 
mittee. On account of this viewpoint it was 
difficult for them to reach but one conclusion, 
that conclusion being that only the State 
could handle this big medical problem and 
that compulsory health insurance was neces- 
sary for its completion. Organized medicine 
strongly objects to both of these conclusions. 
To the first point, we contend that organized 
medicine is the only body equipped by train- 
ing and experience to administer medical 
care. Second, we contend that compulsory 
health insurance is expensive, bureaucratic, 
and detrimental to good medical care. From 
experience gained by countries which have 
Compulsory Health Insurance w-e learn that 
the standard of medical practice is lowered, 
the free choice of physician is not main- 
tained, and that the cost of medical care 
mounts high while the service to the people 
becomes inferior. 

The Attitude of the American Medical 
Associatiou 

The House of Delegates of the American 
Medical Association in session in Chicago in 
September, 1938, approved all the proposals 
of the National Health Committee with 
reserrations, except compulsory health in- 
surance, to which it made strenuous objec- 
tions. Organized medicine is in accord with 
the government health program in the main, 
and it is our duty to do all in our power to 
accomplish the most possible that is good in 
this program. Our difference arises in the 
modus operandi of its accomplishment. We 
must work in harmony to try to accomplish 
our aims, 

F^irst, we know that the medical profes- 
sion is the only group qualified by trainin.g 
or experience to administer or supervise ad- 
ministration of medical care. The govern- 
ment proi)oses to take men with no training 
and no experience, except political, and have 
them advise the doctor how^ he shall treat 
his patient. Could we as physicians advise 



January, 1940 



SOCIALIZED MEDICINE— SIDBURY 



the lawyer, the architect, or the banker how 
to carry out his job? We could, but the re- 
sult would be that the workman would be 
handicapped, and the result of his labor 
would be an inferior product if not a com- 
plete failure. This same type of end product 
will be the result of lay interference in medi- 
cine, in addition to which will be increased 
human suffering. Is this what we want? 

Second, those who are backing this pro- 
gram insist that compulsory health insur- 
ance is the only method that will insure the 
success of this plan. If such be their con- 
clusion, may we suggest another period of 
study, which, if honestly used, would show 
•some evils of compulsory health insurance 
in other countries. Health plans, such as 
are now in use in the United States and 
Canada, demonstrate that the medical pro- 
fession can handle this problem satisfactori- 
ly without interference of the government. 

Third, our federal government is fast ap- 
proaching the constitutional limit of our na- 
tional debt. This proposal would impose an 
additional burden of 4-4' 2 per cent of our 
entire national income. There certainly does 
not exist an emergency of such proportions, 
if any emergency of any kind exists. There 
are other more practical, more economical, 
more satisfactory and more acceptable plans 
of handling this problem, which we advocate 
being tried. Progress in any line is made 
by trial and error. All reasonable opportu- 
nities should be given plans that are now in 
operation or in process of execution whereby 
groups of pensons may receive medical care. 
U is imperative, however, that 0// pUois shidl 
he worked out in colkihoration with the 
medical profeaxion. Today there are 40 
fountries in the world that have State Medi- 
cine or health insurance more or less con- 
trolled by the government. There is not one 
of these .sy.stems which we would want in 
this country. Adoption of any one or part 
of any one of them would lower our .standard 
of medical practice. 

The American Medical Association ap- 
liroves the following recommendations of 
the National Health Association. 

First, the expansion of the public health 
service with the provision that the funds 
spent shall not be used for the treatment of 
patients who are financially able to pay for 
medical care. At this point the rights of the 
private practitioner begin. 



Second, it accepts the mandate that "the 
care of the indigent is the responsibility of 
the government", and the medical and allied 
professions. 

Third, in the matter of expansion of hos- 
pital facilities the American Medical Asso- 
ciation opposes this proposed expansion until 
a definite need is established. There are now 
in the United States 6,800 hospitals, of 
which 6,218 are registered by the American 
Medical Association. These hospitals report 
25-35 per cent of beds unoccupied. If some 
plan could be worked out which would enable 
these unoccupied beds to be used by the in- 
digent and paid for by Federal, State or 
local funds, the existing hospitals would be 
able to render a much greater service to the 
community with much less financial strain. 

The existing hospitals should be encour- 
aged to expand and increase their bed ca- 
pacity before new hospitals are built. The 
majority of the hospitals in this country are 
non-profit institutions. It is easy to see that 
many of these worthy institutions would of 
necessity have to close their doors when gov- 
ernment-run hospitals open to compete with 
them. The hospital load would thereby be 
increased. Grants, as given by the P.W.A., 
should be offered these institutions to help 
them expand to meet the needs. Such a pro- 
cedure would certainly be less expensive and 
would impose less tax burden on the tax- 
payer who is ultimately paying the bill. 
Hospital care for the indigent and the medi- 
cally indigent could well be met in these ex- 
isting hospitals at a per diem rate more 
cheaply than could be done by building, 
equipping and running new government hos- 
pitals. 

Dr. G. Harvey Agnew, President of the 
American Hospital Association, says: 
"American medical greatness was built and 
rests today primarily on private initiative, 
on privately supported voluntary hospitals 
and privately supported teaching and re- 
search associated with them. 

"It is on the voluntary hospitals that our 
municipal and state hospitals depend for 
establishment of standards that pave the 
way to a better future. The voluntary hos- 
pital is absolutely essential to the preserva- 
tion and advancement of high standards in 
medical practice. Those who wish to pre- 
serve the value of private initiative can do 
so if, like the distinguished benefactors who 



NORTH CAIiOl.IN'A MEDICAL JOURNAL 



January, I'.ltO 



have gone before, they help our vohintary 
hospitals to meet the needs of the future. 
Outstanding among these is the need to 
bring good hospital care within the reach of 
those who earnestly desire to be independent 
rather than dependent Americans." 

When the government proceeds to build 
hospitals little attention is paid to cost and 
frequently to needs in the community. An 
illustration of this is strikingly shown in 
Hot Springs. New Jlexico, which has a popu- 
lation of 300. Here a hospital was built for 
the care of crippled children of New Mexico 
at a cost of S2,.500,000 with a bed capacity 
of 90. On one visit to this hospital by a 
representative of the American Medical As- 
sociation, 30 beds were occupied by children 
of New Mexico. Most of the occupants were 
Mexican children who had been sent from 
miles away "for hospital care. The ortho- 
pedic surgeon in charge comes from Texas, 
175 miles away, and he receives for his two 
visits per week to the hospital $2,000 an- 
nually more than does the Governor of New 
Mexico. 

At Fort Worth, Texas, the government 
built a 300 bed hospital for narcotic addicts 
at a cost of $4,000,000. It is estimated that 
one can build and equip a good hospital for 
$4,000 or $5,000 per bed. This one was built 
at the rate of $13,000 per bed. The com- 
mittee examined some 14 different sites 
around Fort Worth and on only one of these 
sites were they able to find a hill, the only 
hill in 200 miles. Removal of this hill was 
the first step in building the hospital. Since 
it snows only once in four or five years in 
Fort Worth, it was deemed necessary to 
connect the building with underground pas- 
sages to prevent exposure going from one 
building to another — another economy 
measure. 

The National Health Committee reports 
that there are approximately 1300 counties 
in the United States which have no general 
hospital facilities. Reports of the American 
College of Surgeons, the American Hospital 
Association and the American ;\Iedical Asso- 
ciation .show that there are only 13 counties 
in the United States which are more than 
30 miles from a good, genera! hospital, or 
speaking in terms of automobiles and good 
roads, only 40 to 50 minutes, distance. 

In eight of these thirteen counties the 
population is 5 or less per square mile. With 



good roads and automobiles a distance of 25 
to 30 miles from a good hospital is cei'tainly 
within reasonable access to good hospital 
care. There is no point in building a hospi- 
tal where there are not enough people to 
support it. 

The establishment of Diagnostic Clinics 
in these more spar.sely settled communities 
could be done at much less expense. They 
would fill the major medical needs of the 
community by rendering valuable diagnostic 
aid to the country doctor. Earlier and more 
accurate diagnoses could be made and hos- 
pitalization in many cases could be avoided. 
The cost of building and operating would be 
many times less than a new hospital scheme 
and instead of competing with the existing 
hospitals they would render valuable assist- 
ance. 

Some of the objections to State-managed 
medicine may be summarized as follows: 

1. The cost of medical care is increased 
tremendously. There are frequently as many 
bureaucratic employees as physicians. 

2. Statistics show us that mortalit.v and 
morbidity rates are increased rather than 
decreased. 

3. Periodic health examinations are not 
encouraged and immunization camiiaigns 
are not emphasized. 

4. Emphasis on preventive medicine is 
not stressed and public health measures arc 
not encouraged. 

5. Overmedication. malingering and neu- 
roses are increased. 

6. The indigent are not satisfactorily 
cared for. 

7. Post-graduate medical education is 
not provided for nor encouraged. 

8. The hospital load is considerably in- 
creased and the practice of medicine by the 
hospital staff is encouraged. 

9. Diagnosis and treatment in the hos- 
pital is apt to become mechanical and sujier- 
ficial and of a low order. 

10. Medical service soon falls into the 
hands of the non-medical man and becomes 
a political issue. 

11. The free choice of physician is dis- 
turbed and the injection of a third i)arty 
into the patient -physician relationship is 
established. 

The advocates of Socialized Medicine in 
this country say that the type of medicine 
liracticed in this country is expensive and 



January, 1940 



SOCIALIZED MEDICINE— SIDBURY 



inefficient. In those countries of Europe 
which have socialized medicine there are as 
many bureaucratic employees as there are 
physicians giving medical service. Red tape, 
government control and political interfer- 
ence take so much of the physician's time 
that little thought and study can be devoted 
to the individual patient's illne.ss. The 
patient ceases to be an individual and be- 
comes a part of mass production. When one 
is ill one most wants to be an individual. 

Those who are advocating State Medicine 
would have us believe that the standards of 
medical practice would be elevated and that 
quackery would be eliminated. Has this 
been the experience of the countries in 
Europe which have Socialized Medicine? 
Germany has had sickness insurance for 54 
years. It is admitted that quacks are thriv- 
ing more in Germany than in any other 
country in the world. Germany is the only 
nation which gives official recognition and 
endorsement to all forms of quackery. Only 
recently Hitler has expelled 3000 regular 
physicians from Germany and to take their 
places he has licen.sed quacks and faith 
healers. 

In 1912 Lloyd George, in a hard fought 
political campaign, to win the election, 
])romi.sed complete health protection to all 
the people. This popular plank in his plat- 
form was the means of his election. The 
British Medical Association bitterly opposed 
it, but when the association saw that it was 
inevitable they accepted it and wrote into 
the law what good features there may be in 
their .system today. This was done over the 
prote.st of the politicians. 

Until 20 or 25 years ago it was a more or 
less universally accepted fact that for a 
doctor to receive a completed, well-rounded 
medical education he had to go to Europe 
for one or more years of post-graduate 
study. What has happened in the last 20 
years to change this status of medical edu- 
cation? Has Socialized Medicine had any 
part to play in this change? Most assuredly 
it has. In this country medical re.search, 
medical education, and independent medical 
liractice have been encouraged by ])rivate 
philanthropy and individual initiative. We 
have not been handicapped by federal regi- 
mentation. Socialized medicine in p]urope 
has lowered medical standards there, while 
we, in this country, have encouraged indi- 
vidual initiative in medical education and 



research and elevated our standards and 
established post-graduate medical education 
in America. Today the Atlantic Ocean sepa- 
rates us from those who have chosen the 
path of State Medicine. Let us hope that it 
will continue to separate us from this mon- 
ster and that we may continue to point with 
pride to America as being the center of post- 
graduate medical education. 

Ontario Plan 

The Ontario Plan which has been in oper- 
ation now for four j'ears is of sufficient in- 
terest to summarize here. The Province of 
Ontario entered into agreement with the 
Medical Society of that Province to provide 
medical care for their indigent. The plan 
is briefly as follows : For each per.son receiv- 
ing relief, including dependents, (which 
totaled 400,000) the government agreed to 
pay 25 cents per month. In return the Medi- 
cal Association of that Province agreed to 
furnish for relief -recipients medical services 
in the office, in the home together with 
obstetrical home service. Complete freedom 
of choice of physician prevailed. 

The medical profession agreed to charge 
the regular fee of $2.00 per office visit and 
$3.00 per house visit and $25.00 for normal 
labor cases, plus mileage allowance. The 
medical profession did not expect to collect 
100 per cent of these charges. Each bill was 
checked as to accuracy and fairness by a 
committee. The total bills were presented 
each month to the proper designated govern- 
ment authority. The total amount was di- 
vided into the amount of the money avail- 
able for each month. Each doctor was paid 
according to his account rendered each 
month. At the end of the two years the 
government increased the pro rata monthly 
allowance to relief recipients to 35 cents per 
month, out of which the druggist was to re- 
ceive 6 cents. 

The records show that the medical pro- 
fession received 45 per cent of bills rendered 
the first year, 38 per cent the .second year, 
and 51 per cent the third year. From this 
we see that the doctors are contributing 50 
per cent of the cost of medical -service to this 
group. 

After this experiment had been in opera- 
tion for four years a letter was addressed to 
the Minister in charge of Health in this 
Province and his reaction to this experiment 
asked. His reply was: "So far as the gov- 



6 



NORTH CAROLINA MEDICAL JOURNAL 



January. 1940 



ernment is concerned, the service is highly 
satisfactory, the medical profession appears 
to be doing a splendid piece of work, the 
relief recipients are satisfied with the care 
they are receiving and the taxpapers who 
are providing the funds (over 4 years, ap- 
proximately four million dollars) are satis- 
fled that they are getting full value for their 
money." 

At no time wa.s there any interference of 
any kind by the government in this experi- 
ment. The experiment demonstrates that 
the medical profession can render satisfac- 
tory medical service to the indigent with 
complete satisfaction to the patient, govern- 
ment and the doctor. 

At the present time there are some 500 to 
600 plans for medical care in operation in 
the United States under the supervision of 
organized medicine. 

If our President, in his re-organization 
program, should see fit to create a portfolio 
of Secretary of Health, and appoint a physi- 
cian to head this department, it is conceiv- 
able that the financing of this Health Pro- 
gram, through him and the United Public 
Health Service, could be accomplished with 
efticiency and economy. The Secretary of 
Health would be chairman of the National 
Health Program. The different states could 
form their committees with the State Health 
Otticer, who holds his office by the will of the 
medical profession of his State, as chairman 
of the State Committee, and ex-officio mem- 
ber of the different county units. The 
county unit could be represented by the 
county medical society, local health officer, 
welfare officer, the mayor, and Chairman of 
the Board of County Commissioners. The 
political office-holders would have to be rep- 
resented because local tax money will be 
necessary to match the federal funds. This 
committee could be empowered to employ a 
welfare worker who would investigate and 
determine the status of the indigent and 
would-be indigent and recommend those de- 
serving such for certification, which certifi- 
cation would be for a specified time, not in- 
definite. This certificate would entitle the 
holder to call the physician of his choice and 
would carry the privilege of hospital and 
medical care by his own physician. 

The fee basis is to be worked out by this 
local committee. The medical society mem- 
bership would be on call just as they are for 



any other patient in the community. A plan 
of payment similar to the Ontario Plan is 
suggested as a fair and workable one. The 
doctors would be paid in proportion to the 
work done and the money allotted in that 
county for that period. 

The medical profession has been accused 
of being selfish, mercenary, stagnant, and 
antiquated. We admit that medical ethics 
by which we are guided are old, but they are 
the only standards which have stood the test 
of time. Their principles are as good and 
as sound today as they were 2000 years ago. 
when Hippocrates first propounded them. 
What other profession gives as much of per- 
sonal service and physical sacrifice as the 
medical profession? Each day of the year 
the medical profession gives in free advice 
and service $1,000,000 and another million 
at cost or below. How much are these re- 
formers giving or willing to give to the 
medically indigent of this country? Most of 
them are after what they can get get out of 
their scheme, not what they can put into it. 

It is incredible ever to think that a lay- 
man can measure with any degree of ac- 
curacy the value of the elements in the 
diagnosis and treatment of a sick patient. 
The only one that has ever been able ac- 
curately and impartially to render this .ser- 
vice anywhere or at any time is the or- 
ganized medical pi-ofession. When the phy- 
sician ceases to have complete control as to 
judgment and treatment of his patient his 
efficiency is instantly weakened and inferior 
service inevitably follows. 

For the past 2000 years the medical pro- 
fession has held to this tradition : "That 
under all circumstances the best possible 
medical care must be supplied to the public. 
No matter what obstacles, legislation, pe.sti- 
lence, flood, famine or war may place in the 
way, the medical profession seeks to adapt 
itself to the situation and give the best ser- 
vice it can." When we oppo.se any .scheme 
or plan which makes it difficult or impossible 
for the doctor to render good medical care, 
the best he is capable of giving, we are liv- 
ing up to this tradition. 

The medical profession in this country has 
always been equal to the task imposed upon 
it. i still have faith that if the American 
Medical Association as an organization is 
given the opportunity of handling the task 
of furnishing medical care to all the peoi)!e 



January, 1940 



SOCIALIZED MEDICINE— SIDBURY 



at a price they can meet, it will do a good 
job with satisfaction to all parties concerned 
if government interference is withheld. 

If the federal government is honestly 
anxious to see that the medically indigent 
be given adequate medical care the profes- 
sion will meet them more than half way. 
The American Medical Association has al- 
ready indicated to the Federal Government 
that organized medicine was glad to consult 
as to plans and to co-operate as to action to 
accomplish the goal toward which all of us 
are striving, that of adequate medical care 
for all the people. 

The existing hospitals as well as the hos- 
pitals of tomorrow must provide accommo- 
dations within the financial reach of the 
great majority of our people who want to 
be self-sustaining. There must be more semi- 
private rooms to meet this demand. There 
must be more small private rooms at low 
cost. It has been the experience of those 
hospitals fostering this plan that these low 
cost accommodations have a waiting list and 
are always in demand. More $4.00 rooms 
and fewer $6.00 and $8.00 rooms will meet 
the needs of our people much more satisfac- 
torily. It is and will continue to be our 
obligation to provide adequate hospital ac- 
commodations for those people of moderate 
and low incomes at a price they can afford 
to pay. 

The time has arrived when the medical 
profession must assert its leadership in its 
own household. We cannot sit quietly by 
and see untrained, unskilled and unscrupu- 
lous politicians assume leadership in medical 
affairs. We will either lead in this cam- 
paign or we will be driven as cattle to the 
slaughter. The demand is imperative and I 
have all faith that the medical profession 
will not be found wanting. 

The public has been informed by means 
of the press, the radio, health agencies, and 
other means of communication that many 
illnesses can be avoided. They have been 
informed that by early diagnosis and good 
medical care many serious illnesses can be 
l)revented. The public wants good medical 
care while sick but they go one step further 
and expect us to conserve their health by 
advising them how to avoid illness. The 
public must be informed more, and repeat- 
edly, of the advances in preventive medical 
measures. We should advise the public by 



every known ethical source that for these 
measures to be most effective they must be 
used by the public. Knowledge is of little 
avail if not put into action. 

The National Health Committee has pre- 
sented a program for study and action. It 
is the duty of the medical profession to study 
its details. What is good and constructive 
we must endorse and support. The objec- 
tionable features we should try to eliminate 
by suggesting a better plan to which we can 
subscribe. 

The medical profession should admit that 
all the people are not getting adequate medi- 
cal care. The financial aid suggested by the 
National Health Program will be gratefully 
received by the profession if it would have 
this help "stand behind the patient, not come 
between the patient and the doctor." Such 
a method of procedure can be worked out, 
I feel sure, with satisfaction to all parties 
concerned — namely, to the public receiving 
the service, to the government giving finan- 
cial aid, and, to the doctor who renders the 
service. 

It is our immediate task to work out ways 
and means of putting into effect this vast 
program that is before us. We cannot shirk 
this responsibility which is ours. With the 
following ideals before us we shall set about 
to perform this task: 

First, that the standards and quality of 
medical practice shall not only be maintained 
but advanced. 

Second, that free choice of physician must 
be maintained as an aid to good medical 
care. 

Third, that we should ever bear in mind 
that the 'poverty of the patient demands the 
gratuitous services of physicians.' 

Fourth, that it is unprofessional for a 
physician to dispose of his services under 
conditions which make it impossible to 
render adequate medical service. 

Fifth, that there shall be no third party 
in the patient-physician relationship. 

I have faith that an effective plan of 
operation can be worked out by organized 
medicine, in cooperation with the federal 
government, by means of which the objec- 
tives outlined by the National Health Com- 
mittee can be attained with satisfaction to 
the government, organized medicine, and the 
public. 

From the result of these conferences and 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



plans now in operation will come a better, 
a stronger and more efficient medical pro- 
gram. Our profession will be bigger, better 
and stronger than ever before and a medical 
care program to meet the needs of our peo- 
ple will have been worked out. This plan 
can and will be worked out by the united 
effort of our entire medical profession. An 
appeal for this unity of action and thought 
is my request. 



LEWIS BURGIN McBRAYER AND THE 
STATE SANATORIUM' 

Chas. H. Cocke, M.D., F.A.C.P., 

ASHEVILLE. 

It was with peculiar pleasure, Mr. Chair- 
man, ladies and gentlemen, that I accepted 
the invitation of your committee to give the 
first address in a series to be made annually 
in honor of the late Lewis Burgin McBray- 
er. I say this honor came to me with un- 
usual pleasure, for my earliest association 
in the practice of medicine in North Caro- 
line was with Dr. McBrayer. The friend- 
ship begun in his private office in Asheville 
in 1912, while he was a member of the 
State Board of Medical Examiners and I 
a candidate for licensure by reciprocity, 
grew and ripened with the years and 
lasted until his death. It was cemented by 
mutuality of interest in tuberculosis work 
and was kept fresh and green by frequent 
contacts and meetings. I am not here to 
recite the many admirable traits and fine 
characteristics of our friend, Dr. McBrayer 
— they are known to you all. But one 
faculty I cannot omit from mentioning, a 
zest and genius for friendship with his fel- 
low doctors that never wavered nor waned, 
a personal interest in them that seemed to 
intensify as he broadened his spheres of ac- 
tivity. By implication, if not by instruction 
from the Committee, this paper is an 
attempt at factual presentation. Proper 
eulogies of Dr. McBrayer have been given 
elsewhere — notably the recent address by 
Dr. Paul H. Ringer at the unveiling of the 
memorial tablet at the Sanatorium. 

Briefly, for the record, what is the story 
of this man? The son of Adolphus and Lou 
Case McBrayer, he was born in Buncombe 

•L. B. McBrayer Memorial Address delivered before the Medl. 
eal Society of the State of North Carolina, May 13. 1939. 



County, N. C, December 27, 1868. A stu- 
dent at Judson College, Hendersonville, N. 
C. in 1883-86, he pursued his medical studies 
in Kentucky, graduating from the Universi- 
ty of Louisville in 1889. The following year 
he married Miss Lillian Cordie Deaver of 
Asheville, N. C, of which union there were 
born three children : Dr. Reuben A. McBray- 
er, at present medical director of the Ciba 
Pharmaceutical Products, Inc., Summit, N. 
J.; Mrs. Sadie L. McCain, wife of our own 
Paul McCain; and Lewis B. McBrayer, Jr. 
Twenty-five years of practice in Asheville 
engaged his energies and time, during which 
period he served as President of the Bun- 
combe County Medical Society ; health of- 
ficer of the City of Asheville (1910-1914) ; 
coroner of Buncombe County (1901-1907) ; 
member of the Board of Health, Buncombe 
County (1909-1914) ; member of the staff 
of the Asheville Mission Hospital ; member 
and sometime President of the State Board 
of Medical Examiners (1908-14); and in 
1915 President of the Medical Society of 
the State of North Carolina. 

In 1914 Dr. McBrajer's interest in public 
health work and preventive medicine led 
him to accept the superinteudency of that 
struggling and ill-nourished infant institu- 
tion of the state, the North Carolina Sana- 
torium for the Treatment of Tuberculosis, 
located at Sanatorium, N. C, accepting also 
the next year the position of Managing Di- 
rector of the North Carolina Tuberculosis 
Association. Thus he began a concrete ef- 
fort at mobilizing the state for the fight 
against tuberculosis, of which, more later! 

In 1921 he became Secretary of the State 
Medical Society, and editor of the Annual 
Transaction.s — positions of trust and respon- 
sibility which he discharged with energetic 
zeal anil dispatch until only the ravages of 
increasing ill health caused a discontinuance 
of his activities in the late months of his 
life. So abounding a vitality as his, how- 
ever active these pursuits and positions 
were, still left him time for interest in other 
national medical organizations, notably 
membership in the National Tuberculosis 
Association and its regional subdivision, the 
Southern Conference on Tuberculosis, of 
which he was president in 1925-26; in the 
American Public Health Association, the 
Tri-state Medical Association, and the 
Southern Medical Association, as well as 



January, 1940 



LEWIS BURGIN McBRAYER— COCKE 



Fellowship in the American College of Phy- 
sicians and the American Medical Associa- 
tion. In addition he served as editor of the 
Section on State Medicine in SOUTHERN 
MEDICINE & SURGERY in 1920. 

Religious and secular affairs also claimed 
the time and talents of this energetic man. 
He was a member of the Baptist Church. He 
early earned a place of prominence in Lodge 
circles — was Grand Master Grand Lodge 
I. 0. 0. F. of North Carolina (1903-04), 
(grand decoration of Chivalry conferred 
1904), Grand Representative from North 
Carolina of Sovereign Grand Lodge I.O.O.F. 
1924, and Grand Marshall Sovereign Grand 
Lodge 1933-34. He also served as President 
of the Sandhill Fruit Growers Association 
in 1922, of the Southern Pines Chamber of 
Commerce in 1929-30, and of the United 
States Number One Highway Association in 
1931. His busy life ended April 1, 1938 at 
the home of his daughter, Mrs. P. P. McCain, 
Sanatorium, N. C. 

What of the fruit of these years of unre- 
mitting toil and almost ceaseless activity? 
It is not possible to assess the proper role 
of one man's activities that have joined the 
efforts of others seeking the same goal. It 
is proper, however, to indicate some of the 
great changes that came about partially as 
a result of his efforts and interest. Such a 
statement detracts not one whit from the 
fair part played by others in these en- 
deavors ; and McBrayer would have been 
the first to acknowledge it, for to him or- 
ganized effort was part of his creed. And 
so without invidious reference, what hap- 
pened to the State Sanatorium and the 
tuberculosis problem of the state during the 
term of McBrayer's connection and activi- 
ties therewith? 

First, a bit of hi.story. It was in 1905 
that Dr. J. E. Brooks of Greensboro tried to 
induce the General Assembly to make an 
appropriation for the establishment of a 
State Sanatorium ; but it was not until the 
next biennial session in 1907 that with the 
aid of Dr. J. R. Gordon of Jamestown, then 
Chairman of the Appropriations Committee 
in the House, he .secured the munificent ap- 
propriation of $15,000.00 for the purchase 
of a site and for the building of a sana- 
torium, and $5,000.00 for the maintenance 
of the same. I would have you contrast 
these figures with the present investment 



of $2,015,000 in the tuberculosis institution 
at Sanatorium, while the Western branch of 
the North Carolina State Sanatorium at 
Black Mountain, opened November 7, 1937, 
represents an additional outlay of $967,- 
553.00. 

Somehow, someway the infant institution 
was opened either late in 1908 or early in 
1909 with a capacity of thirty-two patients, 
under the superintendency of Dr. Brooks. 
After two years of effort under almost 
insuperable difficulties, medical, political, 
financial and otherwise, ill health forced Dr. 
Brooks to retire to private practice, which 
he resumed in Blowing Rock. But a man 
of vision had begun a work that was to 
grow. Dr. Eugene Street succeeded to the 
superintendency until the middle of 1913, 
when the institution was closed, and Dr. 
Street departed. At a special session of the 
Legislature during the fall of 1913, the con- 
trol of the Sanatorium was placed in the 
hands of the State Board of Health. At 
this special session, tuberculosis was made 
a reportable disease, the first forward look- 
ing step in the control of the disease; and 
the State Bureau of Tuberculosis was es- 
tablished. The State Board of Health de- 
cided to separate the business and medical 
departments of the Sanatorium, and Dr. Wil- 
son Pendleton was made Medical Director, 
entering upon his duties in December, 1913, 
while Mr. Tyree Glenn was made business 
manager. Cutting the Gordian knot of 
political, medical and financial troubles that 
infested the about-to-be-reopened sanatori- 
um proved more difficult and distasteful to 
one whose training and bent was clinical 
medicine than Dr. Pendleton cared to cope 
with, and after three months of service he 
resigned in February, 1914. After a credit- 
able service in the World War, in which he 
served as Captain in the Medical Corps, Dr. 
Pendleton entered private practice in Ashe- 
ville, where he has been bu.sily engaged ever 
since. It was into this crisis that Dr. Paul 
P. McCain was summoned as Medical Direc- 
tor following Dr. Pendleton's resignation. 
Like his predecessor, before assuming the 
position, McCain had been assured that the 
institution was in fine financial fettle, where- 
as the truth was that it was in most deplor- 
able financial straits. The in.stitution was 
indebted to so many firms and produce con- 
cerns in the immediate section that its credit 



10 



NORTH CAROLINA MEDICAL JOURNAL 



Januan-. 1940 



had been exhausted to the point where few 
purchases could be made save for cash. Pic- 
ture the scene if you can. There were thirty- 
two patients; there were no electric lights: 
the accommodations were uncomfortable 
and inadequate, even for this small group of 
patients; there was no heat (in February) 
except from open fireplaces ; the institution's 
credit was exhausted; and it was very diffi- 
cult to discover just how much it did owe. 

Dr. !McBrayer came down in April, 1914 
to assume his new duties as Director of the 
Bureau of Tuberculosis. Confronted with 
the chaotic financial situation in the Sana- 
torium and the almost hopeless ta.sk of mak- 
ing it a going concern, with its inadequate 
equipment, facilities and means of support, 
the State Board of Health wisely decided to 
make its Bureau of Tuberculosis Director 
also Superintendent of the Sanatorium. Still 
more wisely they decided to continue Dr. 
McCain as Chief of the Medical Service, add- 
ing to his duties and responsibilities the 
titles of Assistant Superintendent of the 
Sanatorium and Assistant Director of the 
Bureau of Tuberculosis. At last a fumbling 
Legislature had made a double play that 
started the tuberculosis team on its success- 
ful way as a pennant winner. So wideb- 
and favorably known to the profession of 
the entii-e state, being President of the 
North Carolina Medical Society, and like- 
wise well known to so large a portion of the 
public of the state. Dr. McRrayer's appoint- 
ment as Superintendent of the Sanatorium 
was the signal for the prompt re-establish- 
ment of confidence in the institution and the 
restoration of its credit. Brooks Hall, a new 
building then under construction, was com- 
pleted and occupied during the same year. 
Dr. McBrayer assured all creditors of the 
institution that their accounts would be 
paid ; and so persuasive was he in his ap- 
peals to the State Legislature that at the 
next meeting of the General Assembly not 
only was an appropriation made to dis- 
charge all the accumulated indebtedness of 
the Sanatorium, but an appropriation pro- 
viding for seventy additional beds for the 
institution was also secured — quite an 
achievement when one remembers the piti- 
ful inadequacy of former state aid. In 1915 
Dr. McBrayer became JIanaging Director of 
the North Carolina Tuberculosis Associa- 
tion, which Association paid the salary of 



the late Dr. Joseph L. Spruill, who in 191S 
became the first clinic physician. And so, 
with enthusiastic energy but with con- 
sidered judgment under McBrayer's leader- 
ship, the activities of the State Tuberculosis 
Association and the facilities of the State 
Sanatorium expanded steadily. 

Realizing the important role of nursing in 
the treatment of tuberculosis, though not 
primarily charged with the medical care of 
the patients, in 1915 Dr. ^McBrayer estab- 
lished a training school for nurses at the 
North Carolina State Sanatorium, and 
served continuously as its dean until his re- 
tirement in 1924. In 1923 the negro divi- 
sion of the institution was opened, and now 
has 250 beds — still sadly in need of augmen- 
tation. 

In that year the General Assembly re- 
lieved the State Board of Health of the man- 
agement of the Sanatorium, placing it in the 
hands of a special board of nine members 
(appointed by the Governor), of which 
Board Dr. T. W. M. Long was Chairman. 
Dr. McBrayer resigned as Superintendent 
of the Sanatorium in 1924. 

What had the ten years of McBrayer's in- 
cumbency as Superintendent of the Sana- 
torium brought it? An inadequately con- 
structed, ill-equipped, unhealed, and ill- 
nourished building with 32 beds masquerad- 
ing- as a State Tuberculosis Sanatorium had 
grown into a 250 bed, modern, well planned, 
comfortable, efficiently staffed and equipped 
institution, whose work was becoming 
known wherever good tuberculosis work was 
done, a matter of an 800 '"t increase in bed 
capacity alone. It matters little that Dr. 
McBrayer never did participate in the actual 
medical care of the patients. His was the 
organizing, co-ordinating, enthusiastic lead- 
ership that proved how much co-operation 
between the business and the medical de- 
partments of the Sanatorium made for suc- 
cess and enduring results, and above all 
proved the wisdom of placing the activities 
of the Sanatorium under one head. 

Dr. Paul P. McCain, the present distin- 
guished incumbent, whose work has. while 
adding to his fame as a phthisiologist of 
note, likewise reflected deserved recognition 
upon the institution he heads, succeeded Dr. 
^IcBrayer as Superintendent and Medical 
Director. The Bureau of Tuberculosis of 
the State Board of Health then became the 



January, 1940 



LEWIS BURGIN McBRAYER— COCKE 



11 



Extension Department of the Sanatorium, 
and McCain was naturally made Director of 
this. Dr. McBrayer, however, continued his 
activities as Managing Director of the North 
Carolina Tuberculosis Association, with 
headquarters transferred to his home in 
Southern Pines, until August, 1937, when 
failing health caused his retirement from 
this activity. He continued a keen and ac- 
tive interest in the Sanatorium and its Ex- 
tension Department all through the years 
after his participation in its active manage- 
ment. 

As Managing Director of the North Caro- 
lina Tuberculosis Association, he found time 
for a singularly energetic career. Unfor- 
tunately time forbids more than a mere 
mention of some of the high lights of his 
accomplishments in that sphere. He re- 
mained as Director until within a few 
months of his death; and though the Asso- 
ciation had a board of directors and an ex- 
ecutive committee, for all practical purposes 
he was solely responsible for the activities 
of the Association. During the earlier years 
the Association helped buy milk bottling 
equipment for the Sanatorium, and later 
assisted in the purchase of the first x-ray 
equipment. As mentioned earlier, the first 
Clinic physician. Dr. Spruill, was appointed 
in 1918, and his salary continued to be paid 
by the Association until 1924, when this 
work and the expense thereof were taken 
over by the Extension Department of the 
Sanatorium. Employment of the first state 
public health nurse in North Carolina, the 
purchase of a moving picture truck for 
popular instruction and the employment of 
a negro teacher to visit around the state 
showing moving pictures and lecturing on 
subjects pertaining to health, and the em- 
ployment of both a white and colored health 
education worker were some of the forward 
looking activities begun by Dr. McBrayer. 
The annual double-barred-cross seal sale 
came up from almost nothing to the fine fig- 
ure of $40,000.00 during Dr. McBrayer's 
service. 

What was happening to the tuberculosis 
death rate during this decade of active ser- 
vice when Dr. McBrayer spent so much of 
his vital energies and efforts in combating 
disease? In 1915 the death rate from tuber- 
culosis in North Carolina was 156.4 deaths 
per 100,000 population ; while in the year 



1924, when he left the sanatorium, it had 
been reduced to 99.1. These figures are a 
few points above those for the United States 
Registration Area for the same dates ; but 
one must remember they were largely 
augmented by the large number of deaths in 
the mountain section of the state, which was 
then enjoying its peak prosperity as a health 
center by reason of the fame of the doctors 
then engaged in that special work there. I 
feel confident that a separation of the deaths 
legitimately belonging to the citizens of the 
state from those imported to these health 
centers would have shown a record equally 
as fine, if not better than those of the Regis- 
tration Area. For your interest, though it 
may seem a bit foreign to the present dis- 
cussion, this feature of the diminishing 
death rate from tuberculosis has reached the 
point where the provisional figures for 1938 
would seem to indicate only 53.2, an aston- 
ishing drop of two-thirds approximately in 
the last quarter of a century. These figures 
for the state are almost identical with the 
last available figures for the United States 
Registration Area in 1937, when they stood 
at 53.6. 

It would be profitable, but not germane to 
this address, to discuss the many factors 
contributing to this most encouraging fall in 
the death rate from tuberculosis. It would 
be foolish to attempt to give Dr. McBrayer 
too great credit for what is evidently the 
part of a general trend in this disease; and 
yet if time allowed I could quote you parallel 
figures from other communities less active 
in combating the disease than we have been, 
showing quite definitely the enormous value 
of the work done during Dr. McBrayer's ac- 
tive years, and largely under his leadership 
and guidance. 

Of other important activities of the Sana- 
torium which have grown out of these 
earlier efforts of McBrayer and his staff 
much could be said with profit, but that too 
is another story. What concerns us most 
here today is that we pay honor to a man 
who gave up a busy, active practice in his 
home to attack successfully one of the major 
social problems of a medical nature of his 
time. Now why is tuberculosis a social 
problem? In the first place, the cure of 
tuberculosis involves an enormous expendi- 
ture of money, of time and of effort, and 
usually involves the temporary sacrifice of 



12 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



family, friends, ambition and business. For 
another reason, it attacks the young and 
those in their most productive periods of 
life. It tends to disable and to pauperize, 
and of course by its very expensive and pro- 
longed time for cure lowers the entire family 
economic level ; and so you see it is an 
economic problem perhaps even before it is 
a physical one. For cure it means separa- 
tion from all business and physical activities 
for quite a long time. The mere physical 
degree of the disease will, no matter how 
slight to begin with, eventually become 
crippling and fatal if unchecked. Years ago 
Sir Arthur Newsholme pointed out the rela- 
tion of the incidence of the disease to the 
living conditions of the population in which 
it was found; in other words, the lower the 
economic level and the greater the crowded 
conditions of living in too intimate quarters, 
the greater the incidence of the disease. 
This important factor obtains though there 
is a wide divergence in the distribution of 
tuberculosis in various age groups as well 
as in occupational, income and geographical 
groups, not to mention the matter of racial 
distribution. It was a realization of these 
facts and an appreciation also of the great 
truth that whatever improves the physical 
well being and the living conditions and the 
sanitary surroundings of any person or 
group of persons, by whatever measures of 
health activities undertaken, also improves 
the tuberculosis situation immeasurably that 
led Dr. McBrayer's interest into wider fields 
of public health activities than we have time 
to discuss today. 

Almost the whole of the modern effort in 
attempting to stamp out tuberculosis has 
been directed along the lines of education 
and discovery — education of the public to 
make it aware of the dangers, the prevalence 
and the pitfalls of tuberculosis and the op- 
portunities afforded for its early discovery, 
when hopes of arrest and cure are best. The 
distribution of pamphlets, the presentation 
of moving pictures, the delivery of lectures 
and talk.s — but above all the giving of op- 
portunities for examination to masses of the 
IHiblic by the holding of public clinics, and 
the splendid work of tuberculin testing in 
the school and teen age.s — are all parts of 
this campaign, which in this state, as well 
as in many others, has done much to help 
uncover and control the disease. It is axio- 



matic that early and less expensive recovery 
is almost entirely dependent upon early dis- 
covery. The measures I have mentioned fol- 
lowed by the Extension Department of our 
State Sanatorium may not necessarily all be 
attributed to the work of Dr. McBrayer ; but 
they stem directly from the central body of 
his effort, vision and hopes. Had he con- 
tinued in the superintendency of the State 
Sanatorium and as Director of its Extension 
Department, I feel sure his participation in 
these efforts would likewise have been 
crowned with the success that marked his 
other activities. He put his heart, his soul, 
his mind and the abundant energies of an 
active body wholeheartedly into this fight, 
and continued these intei'ests as long as 
physical strength was given him. That he 
lived to see the institution which grew so 
splendidly from its early beginnings reach 
its present place of dominance* in the suc- 
cessful prosecution of the fight against 
tuberculosis must have been indeed all the 
recompense and satisfaction that any man 
could wish for. That he did this too while 
serving his fellow man, notably his fellow 
doctors, in many other valuable capacities 
is reason for gratitude to him on our part, 
and that we all pay fitting tribute to a man 
who was not afraid of work, who loved a 
problem and a difficulty because of the hope 
of solution, to a man who sought new path- 
ways and felt that precedents were more to 
be made than followed when health was to 
be sought, is but his just due. While doing 
these things he still had time to leave the 
impress of his energetic, friendly person- 
ality in the hearts of all who knew him. 
Today we salute his memory and good works. 
Ave et vale, dear old friend Mac ! 

*The present figures represent the facts of today. 
The main division of the North Carolina Sanatorium 
is situated on a tract of 2,100 acres, requirins the 
services of a farming: superintendent, his assistants, 
a dairyman and a poultryman. Total bed capacity 
today is 5.50; but the 75 beds soon to be added to 
the colored unit, including 'J5 at the prison building, 
bring the total capacity to 625. The medical staff 
consists' of the superintendent, four white assistant 
physicians, three colored physicians for the colored 
division, from one to four interns, and a dentist 
who divides his time with the Western Carolina 
.Sanatorium. The nursing staff consists of eleven 
white and six colored graduates, including the white 
and colored superintendent of nurses, while the 
training school is composed of thirty white and 
twenty colored pupil nurses. Four clinic physicians 
conduct diagnostic clinics over the state. The 
Western North Carolina Sanatorium is located 
twelve miles east of As'heville on an undeveloped 
farm of 183 acres; and the present plant consists 



January, 1040 



PNEUMOCONIOSIS— BRUMFIEL 



13 



of the administration building, power house, patients' 
quarters, white and colored cottages, with a present 
capacity of 300 beds, all for white, 30 beds in one 
section intended for patients being used to house 
nurses. The nursing force consists of a superin- 
tendent of nurses, operating room supervisor, eleven 
graduate, four two-year graduates, and fifteen 
practical nurses, while the medical staff consrists of 
the Medical Director, one resident and two assistant 
physicians. 



PNEUMOCONIOSIS' 

D. M. Brumfiel, M. D. 

Saranac Lake, N. Y. 

Within the past decade it is probable that 
no other pathological entity has received 
such widespread interest — one might almost 
say, "publicity" — as has the sub.ject of this 
discussion, pneumoconiosis. Not only has it 
received the attention of the medical profes- 
sion but it has aroused the interest of our 
legal brethren, of industrial management, of 
organized labor, of our law makers and our 
law courts. Even the sob-sisters have taken 
a turn at it. It has literally burst upon our 
general social consciousness in these past 
ten years. Probably, also, there has been 
no other medical subject which has been the 
object of such confusion of thought and 
about which there has been disseminated so 
much misinformation as this same pneumo- 
coniosis. 

Not that it is a new, or even a newly dis- 
covered, disease. Pliny recognized it and re- 
ported its existence as early as 76 A.D. But 
workers in heavily dusty trades were few 
in those days and the first attempt at de- 
scription came post humously from the pen 
of Agricola in 1556. It remained for the 
machine age, however, and more particular- 
ly for modern industrialization, to enter the 
picture and by producing dusts in previous- 
ly-unheard-of concentration cause a serious 
hazard to the health of workmen. A grow- 
ing social consciousness plus the explosive 
effect of the economic depression with its 
unemployment focused the attention of both 
medical and non-medical thought upon this 
peculiar industrial medical problem. 

The term inieumoconioxin has come to be 
ambiguous and should be discarded. It was 
coined to refer to a disease of the lungs due 
to the inhalation of stone dust. Literally, 

'Discussion presented at tlie Symposium on Diseases of tlie 
Chest at Dul<e University, Octotier 19, 19,19. 



and in its most generic sense, it means "a 
condition in which stone dust (inorganic 
dust) is in the lung." In this sense we all 
have pneumoconiosis to a greater or less de- 
gree. Its presence is as inevitable in modern 
life as any other aging process — such as 
graying hair. 

There are as many kinds of pneumoco- 
niosis as there are kinds of inorganic dust, 
e.g. iron — siderosis, carbon — anthracosis, 
silica — silicosis, asbestos — asbestosis, etc. 
But only two known dusts have proven to 
be capable of causing any significant patho- 
logical change in the tissues of the lung, 
namely, free silica and asbestos which is a 
fibrous silicate. Consequently from all clini- 
cal points of view the discussion of pneumo- 
coniosis can be limited to these two specific 
varieties, silicosis and asbestosis. All others 
are of academic interest only at present. 
Certain others are under suspicion but no 
true indictment has been rendered. Nor does 
it seem likely that it will be in view of past 
experience. Other dusts, such as granite, 
have been indicted in the past but in each 
case the substance responsible for the pul- 
monary pathology was found to be the free 
silica present, mixed with the silicate, rather 
than the silicate itself. Of the two, silicosis 
and asbestosis, silicosis is far more impor- 
tant because of the number of men involved. 

The definition of silicosis is both an etio- 
logical and de.scriptive one. "Silicosis is a 
condition in which abnormal fibrosis occurs 
in the lung due to the inhalation of finely 
divided free silica." 

The mere presence of particles of silica in 
the inspired air is not sufficient to produce 
a silicosis hazard. Many other supplemen- 
tary factors enter into the etiology. The 
most important of these are the size of the 
particles, the concentration or number of the 
particles, the length of exposure, the in- 
fluence of other coincidental dusts, and final- 
ly the individual variation of the worker in 
response to the dust. 

As to the size of the dust particles, only 
those of less than 10 microns in size need 
receive our consideration. Larger particles 
are not respirable into the air cells of the 
lungs. With particles of less than 10 microns 
in size it may be said that the smaller the 
particle the greater its toxic effect. 

Equally important with the size of the 
particle is the number of particles present 



14 



NORTH CAROLINA MEDICAL JOURNAL 



Januarj', 1940 



in the air. In human evolution man was 
equipped with defensive mechanisms ade- 
quate to protect him from any untoward 
effect due to a reasonable amount of inhaled 
dust. Modern industrialization has upset 
this balance. The lower border line of safe- 
ty has been arbitrarily set at 5,000.000 par- 
ticles per cubic foot of air, for pure silica. 
Concentrations greater than that figure are 
presumed to be hazardous. 

Just as the body defenses can handle rela- 
tively small amounts of dust successfully for 
a lifetime, so are they able to handle large 
amounts for short intervals. The length of 
exposure is an important factor in the pro- 
duction of silicotic fibrosis. Even in the 
worst conceivable working conditions it re- 
quires two to three years before the lesions 
characteristic of silicosis can be demon- 
strated. In lesser concentrations, especially 
if the silica is mixed with other dusts, it may 
require 20-25 years of constant exposure be- 
fore any pathological change can be detected. 

Other dusts mixed with the silica may 
greatly influence the rate and degree, and 
somewhat the architectural character of the 
pulmonary fibrosis. Pure silica alone has so 
far proven the most productive of patho- 
logical change. In general it is a safe rule 
that mixtures of other dusts tend to inhibit 
the rate of fibrosis. 

Individual variation in response to dust is 
a most intangible factor. It must be a very 
real one, however, tor we have no other ex- 
planation for the fact that not all workmen 
exposed to the same hazard develop silicosis 
at the same rate or to the same degree. 
Many go completely unscathed. 

Where do silicosis hazards occur? How 
widely are they distributed, and how many 
men are involved? There is a potential silic- 
osis hazard in every industrial operation 
that releases a surticient amount of sutflci- 
ently fine silica dust into the atmosphere. 
A few of the more common hazardous occu- 
pations in the recent past have been sand 
blasting, stone cutting, sand pulverizing, all 
hard rock drilling whether in mines or else- 
where, ceramics, abrasives manufacture, and 
foundries. 

It has been estimated that, of the present 
generation of American workmen, approxi- 
mately 500,000 have had significant exposure 
to silica dust. We do not know how many 
of these have contracted silicosis. However 



from the surveys made of representative in- 
dustries it is safe to assume that only 1/5 
to 1/4 of the total will show any silicosis 
whatever — a round number of perhaps 120,- 
000. Experience in the same representative 
industries shows that only a minority of 
those showing x-ray evidence of silicosis 
suffer disability as a result. That leaves us 
a much smaller number, probably only a few 
thousand, potentially symptomatic silicotics. 
The remaining majority would have lived 
out their allotted span undiagnosed had not 
the surveys been carried out. 

A brief review of the pathogenesis and 
pathology of this condition is indispensable 
to an understanding of its subclassifications. 
each with a characteristic x-ray pattern, and 
therefore to the diagnosis. As will be pointed 
out later the major crux in diagnosis lies in 
the x-ray, and an intelligent interpretation 
of the shadows seen depends upon an under- 
standing of the pathological conditions which 
these shadows reveal. 

We recall that the lung, anatomically, can 
be roughly likened to a tree, the trunk of 
which is represented by the trachea, and the 
individual leaves correspond to the individu- 
al air sacs, or alveolae. The entire paren- 
chyma is abundantly supplied with lymph 
spaces which open into lymph channels. 
Those near any of the surfaces drain into 
the subpleural channels which course cir- 
cumferentially to the hilum. All others drain 
toward the hilum and are intimately asso- 
ciated with the branches of the pulmonary 
vessels. 

When dusty air is inhaled a considerable 
number of the particles are screened out by 
the gross mechanisms of the nasal passages, 
the moist trachea and larger bronchi. How- 
ever, this is not adequate to remove all the 
particles in atmospheric suspension, and 
many reach the alveolae. Of those which do 
enter a few will adhere to the walls of the 
air cells. Here they are picked up by wan- 
dering phagocytes which then return to 
tissue spaces and start making their way 
into the lymph channels on a general migra- 
tion toward the hilum, many actually reach- 
ing the peribronchial and tracheo-bronchial 
lymph nodes. Many will be trapped in the 
tiny aggregations of lymph tissue which lie 
along the course of the lymph channels. As j 
this trapping and retention of dust-laden 
cells continues there will come a time when 



January, 1940 



PNEUMOCONIOSIS— BEUMFIEL 



15 



the total effect of these accumulated deposits 
will actually increase the diameter of the 
relatively radio-opaque vascular sheath. This 
in turn is caught on the roentgenogram as 
an exaggeration of the normal linear mark- 
ings which represent the vascular tree. 
These same deposits subpleurally give the 
lung surface its pigmentation, particularly 
if the particles be carbon. 

If the dusts inhaled are inert, such as 
gypsum, cement, marble, carbon, etc., no 
further development occurs. Sections of the 
lung merely reveal continuous little ash 
heaps of dust-bearing cells along the course 
of the perivascular lymphatics. The sur- 
rounding tissues are not stimulated to 
fibrosis formation and there is apparently 
no interference with normal pulmonary 
physiology. As has already been stated this 
condition, when sufficiently well developed, 
registers on the x-ray film and has been 
variously recorded as "perivascular infiltra- 
tion", "perilymphatic infiltration", "exag- 
geration of the linear markings", and most 
unfortunately as "more fibrosis than usual". 

While this last term was coined several 
years ago by the Miner Phthisis Medicolegal 
Bureau of South Africa to apply to this 
variation in the x-ray appearance of healthy 
lungs, the inclusion of the word "fibrosis" 
has caused no end of confusion not only in 
the minds of the medical men but in the 
courts. The word "fibrosis" carries the 
implication of tissue reaction — a definite 
pathological process — and we now know 
from microscopic studies that fibrosis is 
either insignificant or wholly absent. Many 
cases have been mistakenly labeled silicosis, 
and so taken to the compen.sation courts with 
nothing more than this innocuous linear ex- 
aggeration in the x-rays. 

Such films are not even pathognomonic of 
dust deposits. Any alteration within the 
lung that will increa.se the caliber or density 
of the vascular sheaths will duplicate this 
pattern in the roentgenogram. Among such 
conditions are pulmonary arteriosclerosis ; 
chronic bronchitis with peribronchitis; pul- 
monary congestion due to failing circulation. 
Of cour.-^e, with chronic infections and con- 
ditions impairing the oxygenation of the 
tissues some fibrosis may be present. 

When large amounts of silica enter the 
scene the picture changes. When large num- 
bers of cells bearing silica particles come to 



rest in a given area they eventually stimu- 
late the adjacent tissue to the formation of 
fibrosis. Each aggregate of particles acts 
as a focus and gradually a concentrically in- 
creasing nodule of fibrous tissue is built up 
about this center. Soon, pathologically, the 
finer lymph channels become partially oc- 
cluded so that the central migration of the 
wandering dust cells is impeded and some 
of them delay in the extra vascular paren- 
chyma long enough to become foci of fibrosis 
there. Hence occurs the simultaneous ap- 
pearance of discreet nodules uniformly dis- 
persed throughout the lung fields. The sili- 
cotic nodule is characteristic. It is firm, 
.sharply outlined, without a peripheral in- 
flammatory zone, and is composed of whorls 
of fibrous tissue which hyalinize. These then 
are the characteristic pathological lesions of 
silicosis — innumerable, discreet, sharply out- 
lined nodules — which transmit their num- 
ber, distribution, shape and definition to the 
x-ray film. 

This is briefly the picture of Simple, or 
Uncomplicated, Nodular Silicosis — the class- 
ification that embraces the great majority 
of all cases. This is further divided into 
arbitrary stages — first, second, and third, 
depending on the size of the nodular 
shadows. Stage I may be roughly described 
as any nodulation visible on the x-ray film 
up to those 2 mm. in diameter, and Stage 
III as that stage in which the nodules have 
become so large that some are on the point 
of being contiguous. In these more advanced 
stages there will be seen compensatory em- 
physema at the lung bases and peripherally. 

In contrast with the Simple Nodular Sili- 
cosis we have a group of cases designated as 
Silicosis with Massive or Conglomerate 
Shadoivs. The roentgenograms of these 
cases show a background of the character- 
i.stic nodulation with localized massive or 
conglomerate densities. These may be but 
small conglomerations of nodules still recog- 
nizable as such, but packed together in one 
locality and more numerous and larger than 
the nodules elsewhere. All gradations occur 
between this small localization and huge uni- 
form opacities occupying the greater portion 
of both lung fields, and so dense that all 
architecture has been lost. These latter are 
accompanied by extreme basal and periphe- 
ral emphysema. 



16 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



Microscopically the typical nodules are 
still recognizable here and there in the more 
massive lesions but have now become so 
firmly imbedded in a matrix of general 
fibrosis that they have become an integral 
part of a hard, hyalinized fibrous area. In 
the less compact lesions and the small areas 
of conglomeration the nodules dominate the 
microscopic picture, being merely bound to- 
gether and more or less integrated by fibrous 
strands. 

The complete etiology is not clear for all 
of these conglomerate and massive lesions. 
In Saranac Lake we agree with Dr. L. U. 
Gardner that the most likely explanation for 
their existence lies in the combined action 
of silicotic fibrosis and infection. It is true 
that in some of the more massive lesions no 
histologic evidence of infection can be found, 
but in the majority of them and in practi- 
cally all of the less massive and smaller con- 
glomerations elements of infection are dis- 
covered. This conclusion is further sup- 
ported by the fact that we have observed 
such lesions later break down with unmis- 
takable progressive infection when followed 
with serial films. In those cases where no 
evidence of coexistent infection occurs, we 
presume, rightly or wrongly, that the pecu- 
liarities of the lesion were brought about by 
a previous infection which had long since 
burnt itself out. Animal experimentation 
also supports this theory. 

The third and last group of silicotics are 
those classed as Silicosis with Infection or 
Infected Silicosis. As the previous com- 
ments would indicate this group overlaps 
and embraces many, if not all, of the cases 
classed as Conglomemte Silicosis. When 
recognizable antemortem infection occurs, it 
is almost invariably tuberculosis. The back- 
ground of diffuse silicotic nodules is present, 
as always. The roentgenographic appear- 
ance reflects the pathology within the lung. 
The most important criterion is the appear- 
ance of ill defined shadows in contrast to the 
sharply limited shadows cast by uninfected 
silicotic nodules. This may vary in all grada- 
tions from a small barely discernible local- 
ized smudge to a state in which an over- 
whelming progressive bilateral tuberculosis 
has completely blotted out the original 
pattern of nodulation. As the individual 
nodules themselves become the site of in- 
fection their sharp edges lose their defini- 



tion and blurr off insensibly into the sur- 
rounding healthy lung pattern. In those un- 
usual cases in which an overwhelming ex- 
ogenus tuberculosis supervenes on the back- 
ground of an established silicosis all the 
nodules appear to blossom simultaneously. 

The clinical picture of silicosis can be 
quickly summarized. In contrast to most 
pathological entities, silicosis presents no 
pathognomonic sj-ndrome, no characteristic 
symptom complex. It is true that we read 
of the fixed chest, the dyspnoea, the chest 
pain, the sputum — scanty, glassy and blood 
tinged, or copious and muconurulent. Among 
the physical signs we are told of limited chest 
expansion, cyanosis, hyperresonance, pro- 
longed and suppressed breath sounds, 
clubbed fingers, a various assortment of 
rales. But these same symptoms and signs 
are, individually and in groups, found to 
belong to other conditions and in individuals 
in whom no suspicion of silicosis can exist. 
It is the writer's firm belief that silicosis 
remains symptom-free until some complica- 
tion develops. The possible exception to this 
generality is that a simple uncomplicated 
silicotic may become so far advanced that 
the accompanying emphysema may handicap 
him. Even that might come under the head- 
ing of complications without stretching the 
point too far. In those cases which do be- 
come symptomatic the onset of symptoms is 
so insidious that it has been stated that the 
first symptom is a decrease in the pay check 
of the piece-worker — due to his slowing 
down in working efliciency. 

To clarify this problem in my own mind 
I have divided all silicotics into two groups 
or two stages: the first, PtecUnicul or 
Asymptomatic Silicosis: the second. Clinical 
or Sijmptomatic Silicosis. Again quoting the 
estimates given earlier there will be approxi- 
mately 100,000 in the first group and a very 
much smaller number in the second. In this 
latter or symptomatic group will be: fir.st, 
those extremely far advanced cases of simple 
silicosis with disabling emphysema: second, 
those with active infection: and third, a 
group with cardiovascular disorders in 
whom pulmonary fibrosis creates an addi- 
tional handicap. The symptoms and signs 
will be tho.se inherent in the complicati<in. 
whether emphysema, pulmonary infection in- 
an embarrassed circulation. 

Silicosis can not be diagnosed from the 



January, 1940 



PNEUMOCONIOSIS— BRUMFIEL 



17 



clinical picture. At most it can be suspected 
if the afore-mentioned complications occur 
in more than their normal frequency among 
a group of workmen exposed to a siliceous 
dust, and a thorough investigation should 
follow. There are two indispensable criteria 
in the diagnosis of silicosis, and only two. 
They must both be present for the same in- 
dividual before such diagnosis is permissible. 
These are, first, a history of significant ex- 
posure, and second, an x-ray bearing the 
characteristic nodular patterri in the lung 
fields. One without the other is not enough. 
There are occasionally other conditions 
which simulate the x-ray pattern of silicosis 
so well that diagnoses of silicosis have been 
made in men who were never exposed. And, 
on the other hand, men have also received 
the same diagnosis simply because they 
worked in a siliceous dust irrespective of the 
fact that their lungs showed nothing in the 
roentgenogram. We know that many men 
so exposed escape unscathed. 

The course of silicosis is that of extremely 
slow progression pathologically if the indi- 
vidual remains exposed to the harmful dust. 
The progression is to be measured in years 
rather than months, and in the majority of 
cases will not become symptomatic within an 
average lifetime unless complications super- 
vene. 

The progress depends on the complica- 
tions. Silicosis per se is not a fatal disease. 
In considering those cases complicated by 
cardiovascular disorder we must remember 
that these men are usually in the age-grou)) 
subject to the degenerative cardiovascular 
disease by the time they acquire their silic- 
osis. We have seen several cases with mas- 
sive conglomerate lesions who have died of 
congestive heart failure. By far the most 
important complication is tuberculosis. Were 
it not for tuberculosis, silicosis would be a 
relatively negligible condition. 

Tuberculo-silicosis is a large subject by 
itself. Suffice it to say here that silicosis 
definitely predisposes to tuberculosis and 
that when active tuberculosis becomes 
established in a silicotic individual the prog- 
nosis is much more unfavorable than in the 
non-silicotic. Also the majority of the tu- 
berculo-silicotic individuals pass through a 
long chronic period of very low toxicity be- 
fore the infection becomes evident, so that 
the tuberculosis is very likely to become well 



advanced before it is suspected. Every sili- 
cotic individual with localized shadows in 
the lung fields should be re-x-rayed at fre- 
quent intervals in spite of his protestations 
of perfect health. In no other way will the 
early progression of his infection be detected 
in time for him to enjoy a normal life ex- 
pectancy. 

No discussion of this general topic of 
pneumoconiosis would be complete without 
further mention of asbestosis, especially 
here in North Carolina where many of our 
important American contributions to the 
subject have originated. While silicosis and 
asbestosis are both fundamentally conditions 
of abnormal pulmonary fibrosis, they differ 
widely in their pathogenesis, pathology, and 
clinical pictures. The particulate fibers of 
asbestos are too long to be taken into the 
alveoli of the lungs. They are picked up in 
the terminal bronchioles and become im- 
bedded in the walls of these structures. 
Here they stimulate fibrous tissue reaction 
and the result is a fibrous cuff encircling the 
bronchiole, thickening the parenchymal wall, 
and partially stenosing the air passage. In 
far advanced cases the stenosis is sufficient 
to cause miliary atelectasis beyond the point 
of constriction and miliary emphysema of 
adjacent unaffected areas. All these factors 
contribute to an embarrassment of the respi- 
ratory and circulatory functions. Adhesive 
pleuritis is common and extensive pleuro- 
pericardial adhesions lead to the so-called 
"porcupine heart" shadow seen in the x-rays 
of far advanced cases. The roentgenogram 
bears no resemblance to that of silicosis. A 
general haziness or so-called "ground glass" 
appearance prevails, more prominently in 
the lower half of the lung fields, together 
with the aforementioned evidence of ad- 
hesive pleuritis. On close examination of 
the films, particulai-ly in stereo, this ground 
glass appearance resolves itself into a deli- 
cate reticulum of faint shadows, produced 
as the natural consequence of the thickened 
pulmonary stroma. 

This peculiar distribution of pathological 
fibrosis accounts for the fact that the victim 
develops dyspnoea comparatively early and 
that a considerable number of the advanced 
cases are reported to show right-sided 
cardiac enlargement and clubbed fingers. In 
the presence of organic heart disease of any 
sort the outcome is obvious. American ex- 



18 



NORTH CAROLINA MEDICAL JOURNAL 



Januai->', 1940 



perience does not indicate that asbestosis 
predisposes to tuberculosis, in contrast to the 
opinion in England. The clinical difference 
between silicosis and asbestosis is as marked 
as their pathological difference. 

In dealing with silicosis the examiner is 
astonished that men who show lungs studded 
with silicotic nodules should refuse to admit 
symptoms, while with asbestosis he is equal- 
ly astonished that men with so little to see 
in the x-ray should experience a definite 
physical handicap. 

There are still many gaps in our know- 
ledge of these individual pulmonary fibroses. 
Our first clinical impressions were derived 
from observations on the poor tuberculo- 
silicotics who waited their end in our alms 
houses, hospitals and sanatoria. Our first 
knowledge of the pathology came from ob- 
servations made upon the same cases after 
the end had come. But these were all read- 
ings made from the last chapter of the book. 
These studies were later supplemented by 
some insight into pathogenesis as discovered 
by the experimental pathologist in his ani- 
mals. This gave us a sort of beginning to 
the story of which we had already seen the 
end. When health surveys began to be made 
in industry we were appalled by the number 
of men showing dust fibrosis and jumped to 
the conclusion that these thousands upon 
thousands were all destined to cough their 
lives away as had their predecessors in the 
alms houses. No wonder there was hysteria 
and panic in indu.strial medicine and in in- 
dustry it,self. Further animal experimenta- 
tion, more comprehensive health surveys, 
longer periods of observation of men by 
serial x-rays and more sober consideration 
of the available facts have led to a revalua- 
tion of the whole problem and the hysteria 
is dying a natural death. Within another 
generation the major industries will have re- 
moved the hazards by mechanical means. 
But we still have the present generation of 
silicotics to consider. We still need to know : 
how rapidly nodulation progresses when 
once established ; what is the threshold ex- 
posure beyond which silicosis will become 
self progressive even though further ex- 
posure is removed ; what percentage of the 
preclinical silicotics now in existence will 
develop complications and become disabled : 
how we can diagnose the infected case 



earlier; how we can best treat him, and 
many other pertinent facts. 

The experimental pathologist, the bio- 
chemist, the industrial physician and the 
governmental health agencies are all doing 
their part in attacking this problem. But 
there is a definite and important part that 
can be played by the practitioner better than 
by anyone else. He can do a great deal to 
help identify silicosis hazards and run them 
down in unsuspected places. He already has 
the confidence of the workmen and his 
family and can use his influence in getting 
x-rays and other examinations of employees 
in small industries and individual enter- 
prises in which there is some suspicion of 
a silica hazard. Equally as important as 
diagnosing silicosis where it exists is the 
prevention of its diagnosis where it does not 
exist. Thus he may save mental anguish, 
litigation and injustices to both employer 
and employee. 



THE VARIOUS FORMS OF 

ENCEPHALITIS* 

Bernard J. Alpers, M.D., Sc.D. (Med.) 

Philadelphia 

It is essential to have clearly in mind some 
idea of the various forms of encephalitis for 
purposes of both diagnosis and treatment. 
In the minds of most practitioners, and in- 
deed of some neurologists, encephalitis com- 
prises a more or less indistinct group of en- 
tities, poorly-defined pathologically and clin- 
ically. While there is some ground for this 
belief, the fact remains that what is known 
constitutes a good basis for a clinical group- 
ing of a much confused problem. Further- 
more, a knowledge of encephalitis in its va- 
rious forms tends to clear the mists from 
the generic diagnosis "encephalitis", which 
more often implies ignorance of the diagno- 
sis than a knowledge of encephalitis. It is 
wise to avoid the u.se of the term "ence- 
phalitis" as a diagnosis by exclusion, and to 
know exactly what form of encephalitis is 
meant. In this way many of the pitfalls 
which accompany the diagnosis may be 
avoided ; for too often the diagnosis of en- 
cephalitis is made without any knowledge 
concerning the type with which one deals. 

From the Department of Neurolo^-. .lefferffnn Medical Col- 
letre. Philadelphia, 

Part of a Presentation delivered before the Guilford County 
and Fors>-th County Medical Societies in Greensboro, N. C. 
September 12. 1939. 



January, 1940 



ENCEPHALITIS— ALPERS 



19 



It is primarily for this reason that I feel it 
wise to discuss a much belabored subject. 
My object is threefold: (1) to point out the 
various forms of encephalitis as a back- 
ground for a working knowledge of the sub- 
ject, (2) to emphasize the fact that a diag- 
nosis of encephalitis by exclusion should be 
avoided, and (3) to point out that if a 
diagnosis of encephalitis is made, it should 
be made with a full knowledge of the specific 
type of encephalitis with which one is faced. 
Classification. 

There are many classifications of the en- 
cephalitides. All of them are based on neu- 
ropathological studies. Some are too inclu- 
sive, others are too exclusive. 

For purposes of simplification I shall de- 
fine encephalitis as a disease of the brain 
characterized by evidences of inflammation, 
the term "inflammation" being used in a 
broad sense. This is a definition largely 
from the standpoint of the neuropathologist. 
Clinically speaking, encephalitis is any in- 
flammatory disease involving the brain. 
Such a definition would include many forms 
of meningo-encephalitis, such as general 
paresis, tuberculous meningo-encephalitis 
and other disorders ; hence I shall confine 
myself to a narrower concept of the en- 
cephalitides, granting of cour.se that in the 
strict sense of the word the various forms 
of meningo-encephalitis should be included. 

For purposes of discussion the following 
grouping of the various forms of encephali- 
tis seems best : 

1. Polioencephalitis 

2. Metastatic Encephalitis 

3. Acute Demyelinizing Encephalitis 

4. Chronic Demyelinizing Encephalitis 

5. Perivenous Encephalitis 

6. Hemorrhagic Encephalitis 

7. Miscellaneous Types of Encephalitis. 
This grouping includes all the important 
forms of encephalitis, and excludes others 
which are not ab.solutely essential to the dis- 
cussion. 

Polioencephalitis. 
The polioencephalitic form of encephalitis 
is frequently referred to as the poliocla.stic 
variety or the patchy type of encephalitis. 
It includes a number of conditions such as 
poliomyelitis, epidemic encephalitis, herpes 
zoster, and rabies. These diseases are groupetl 
together under the term polioencephalitis be- 
cause from the pathological standpoint they 



have the characteristic of attacking the gray 
substance of the brain and spinal cord in 
varying degree. The classification is based 
on pathological characteristics; it by no 
means implies that all these diseases have a 
similar etiology. 

The various diseases grouped under polio- 
encephalitis have similar histological fea- 
tures ; so much so that without previous 
knowledge of the history it is impossible 
from their histological features to differ- 
entiate one from the other. They differ 
largely in the locus of the disease process 
and in their mode of access to the nervous 
system. Poliomyelitis, for example, involves 
primarily the anterior horn cells of the 
spinal cord, but it may, and often does ex- 
tend to the gray matter of the medulla, pons, 
midbrain, and diencephalon ; or it may even 
involve the cerebral cortex, particularly the 
motor cortex. It may at times affect only 
the base of the brain without disease of the 
spinal cord. Epidemic encephalitis, on the 
other hand, is prone to attack the midbrain, 
especially the region around the aqueduct of 
Sylvius; it may extend into the pons and 
diencephalon or the basal ganglia, and it 
may on rare occasions involve the spinal 
cord. Rabies aflfects primarily the base of 
the brain, especially the medulla, but extends 
eventually into the spinal cord also. While 
the histopathology of rabies is similar to 
that of other members of this group, it may 
be distinguished definitely by the presence 
of Negri bodies in the diseased ganglion 
cells. Herpes zoster, the other of this group, 
involves primarily the posterior root gang- 
lia, and the posterior horns of the spinal 
cord. It may, however, give rise to a typical 
encephalitis associated with herpes ophthal- 
micus involving the first division of the 
trigeminal nerve. Herpes encephalitis can- 
not be distinguished microscopically from 
epidemic encephalitis. 

The grouping of poliomyelitis, epidemic 
encephalitis, rabies, and herpes zoster forms 
a convenient method of allying these impor- 
tant forms of encephalitis based on the 
similarity of their microscopic features. It 
tells us nothing concerning their etiology, 
and but little about their pathogenesis. In 
a very wide sense it is a grouping of con- 
venience both for the pathologist and for the 
clinician. 

While the various members of the polio- 



20 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



encephalitis group have a similar histology, 
their pathogenesis differs widely. Polio- 
myelitis enters the nervous system through 
the olfactory nerve and tracts, and extends 
into the brain and spinal cord by way of 
the hypothalamus and other parts of the 
brain stem. Rabies invades the nervous sys- 
tem by means of injection through a bite. 
The mode of entrance of herpes zoster and 
epidemic encephalitis is not known. If any 
conclusion can be drawn concerning the his- 
tological similarity of poliomyelitis, epidemic 
encephalitis, herpes zoster, and rabies, it is 
simply that they are probably all virus di- 
seases. The evidence is good for poliomyeli- 
tis, herpes zoster, and rabies, and is fairly 
conclusive for epidemic encephalitis. 

It would take me too far afield to discuss 
even briefly the clinical features of the va- 
rious members of this group, so that I must 
be content mei*ely to call attention to their 
histological similarity in the hope that such 
a grouping may serve to throw some light 
on clinical pi'oblems. 

Included in this group of encephalitides 
are two special forms of encephalitis known 
as the St. Louis type encephalitis and 
Japanese B encephalitis. Japanese enceph- 
alitis has been known for several yeai's, the 
disease occurring in epidemic form during 
the hot season. The St. Louis type of en- 
cephalitis is somewhat similar clinically to 
the Japanese type. The clinical manife.sta- 
tions vary greatly, and include meningeal 
signs — confusion, diplopia, sleeplessness — 
and other evidences of brain stem involve- 
ment. The disease is caused by a virus, has 
a mortality of only 20 per cent, and differs 
utiologically from the virus of Japanese en- 
cephalitis. The two viruses are not identi- 
cal. Pathologically, St. Louis encephalitis is 
characterized by foci of lymphocytic intiltra- 
fion in the tissue, with perivascular infiltra- 
tion and with much more extensive involve- 
ment of the nervous system than in lethargic 
encephalitis, the damage involving the cortex 
and other parts of the brain in addition to 
the brain stem. 

Metastatic Encephalitis. 
The group of cases included under the 
term metastatic encephalitis constitute a 
very important clinical group. They form 
a group of encephalitis from various causes 
with a similar histological picture. They are 
spoken of as cases of metastatic encephalitis 



because the encephalitis which is found in 
such instances is the result of foci elsewhere 
in the body. This form of encephalitis con- 
sists of foci which may attack any part of 
the brain or brain stem. They rarely in- 
volve the spinal cord. They have a predilec- 
tion for the gray matter, but they may affect 
also the white substance to a much lesser 
degree. The nervous system in such cases 
is spattered with discrete foci which may be 
numei'ous or may be quite few in number. 
I have seen brains riddled with such foci, 
while in other instances I have had to search 
carefully for a few areas at the base of the 
brain. Histologically, the foci are composed 
usually of discrete collections of polynuclear 
cells in the gray substance, with extension 
of the exudate into the surrounding tissue 
and with peri-vascular infiltrations with 
polynuclear cells. There is usually no menin- 
geal reaction unless one of the foci lies ad- 
jacent to the subarachnoid space. Essential- 
ly the process may be described as miliary 
abscesses. Strictly speaking it is an en- 
cephalitis. In some instances this form of 
encephalitis is associated not with polynuc- 
lear infiltrations, but with punctate hemor- 
rhages. 

Clinically, metastatic encephalitis may 
arise from cardiac disease, lung abscess, sep- 
ticemias, tooth extractions and bronchiec- 
tasis. In heart disease it is most often found 
as a complication of subacute bacterial en- 
docarditis, but it may occur also during the 
course of rheumatic endocarditis. In cases 
of subacute bacterial endocarditis the metas- 
tatic encephalitis is often terminal, but not 
necessarily fatal. Cases not infrequently re- 
cover if the extension is not too severe. The 
onset of cerebral symptoms in such cases is 
sudden and apoplectic, and may or may not 
be associated with fever. The signs vary 
with the particular area involved. Similar 
uncephalitic manifestations occur during the 
course of septicemias from various causes, 
and here the matter is one largely of aca- 
demic interest; though in these days of 
chemotherapy even some of these may re- 
cover. 

Particularly instructive are the cases of 
metastatic encephalitis which develop after 
the extraction of ab.scessed teeth. Several 
instances of this sort have been recorded. 
I myself have seen and studied five. The 
encephalitis in such cases follows soon after 



January, 1940 



ENCEPHALITIS— ALPERS 



?1 



tooth extraction, is sudden and abrupt in 
onset, associated with fever, and may pro- 
duce monoplegias, focal convulsions, or other 
signs of cerebral damage. The encephalitis 
in such cases may be part of a blood stream 
infection, in which case the outlook is poor, 
or it may a focal manifestation with full 
recovery. 

It is not uncommon to see cerebral com- 
plications accompanying lung abscess or 
bronchiectasis. Such complications consist 
usually of brain abscess, but a metastatic 
encephalitis is also not infrequently found. 
The differentiation between the two condi- 
tions is often very difficult in the ficute 
stages. They may both give rise to focal 
signs, such as focal convulsions, aphasia, or 
hemiplegia, but the cases of metastatic en- 
cephalitis usually show no signs of increased 
pressure and no increase of cells in the 
spinal fluid. Cases of this sort which re- 
cover from their cerebral symptoms may, 
of course, be attributed to encephalitis 
rather than abscess. 

Acute Demyelinizing Encephalitis. 

In this group one finds largely the cases 
of acute encephalomyelitis disseminata and 
equine encephalomyelitis. This is a disorder 
characterized by patchy disseminated areas 
of tissue destruction. They may involve the 
brain and brain stem and the spinal cord ; 
they may be confined to the brain and brain 
stem ; or they may implicate the spinal cord 
predominantly. The areas of encephalomye- 
litis involve both the gray and white matter, 
but .show a preference for the latter. Their 
number varies greatly ; they may be nume- 
rous or few. Histologically, they are charac- 
terized by destruction of the tissue in dis- 
crete patchy areas, with loss of myelin, axis 
cylinders, and active phagocyte activity. The 
vessels both within and around the areas of 
destruction often show perivascular infiltra- 
tion with lymphocytes and plasma cells. 

Clinically, disseminated encephalomyelitis 
often follows upper respiratory infection, 
and is characterized by an abrupt onset, 
fever, and varied clinical signs depending on 
the areas involved. Paralysis of one side, 
of the legs, or of all the extremities, a sen- 
sory level, bladder and rectal di.sturbances, 
and cranial nerve signs may be found in 
varying combinations. Usually there is a 
leucocytosis. The spinal fluid may show an 
increase of cells if the patient is studied in 



the acute stage of the disease. The cause is 
unknown. The disease has been reported 
after influenza and the grippe. It is re- 
garded as a virus infection, though no good 
evidence has been put forward to support 
this conception. 

Recent years have revealed a new form of 
acute encephalitis. This is an equine en- 
cephalomyelitis which has been found to ap- 
pear in man in epidemic form in the eastern 
and western parts of the United States. It 
is divided into the eastern and western forms 
of equine encephalomyelitis in man, because 
of differences which occur in the two forms. 
The virus of the eastern form differs sero- 
logically from that of the western type. 
Both types are characterized by diffuse 
necrotic foci with inflammatory and degen- 
erative lesions. The clinical onset is abrupt 
with high fever and severe prostration, with 
a preponderance of polynuclear cells in the 
spinal fluid. The mortality in the eastern 
group is high (65 per cent). In 8 fatal 
faces a virus was isolated from the brain 
tissue, but the virus was not found to be 
the same in all instances. Five different 
types of virus have been recovered. A mos- 
quito vector is said to carry the disease. A 
virus has been recovered from human blood 
serum in the western type of equine enceph- 
alomyelitis. There is also a Venezuelan and 
Argentinian form of equine encephalomyeli- 
tis, but so far no cases have been recorded 
in human beings. These forms of equine 
encephalomyelitis appear to be different 
from the American types. 

Chronic Demyelinizing Encephalitis. 

In this group of encephalitides may be in- 
cluded multiple sclerosis, encephalitis periax- 
ialis diffusa (Schilder's disease), neuromye- 
litis optica (Devic's disease), and a rare 
form of enchephalitis, the enchephalitis con- 
centrica of Balo. 

Multiple sclerosis is well known and needs 
no extensive comment. In a broad sense it 
may be included among the encephalitides, 
since it has many of the features of enceph- 
alitis. It is a chronic demyelinizing disease 
characterized by areas of tissue destruction 
involving the spinal cord, brain stem, cortex, 
and optic nerves and tracts. It is character- 
ized histologically by destruction of myelin 
in the affected areas, the relative preserva- 
tion of the axis cylinders, and the formation 
of glial scars. The etiology is unknown. The 



22 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



present day conception is that the patches 
of multiple sclerosis result from vascular 
occlusions from causes unknown ; the specific 
etiology still remains unsolved. Recent 
studies seem to indicate that occlusion of 
vessels by thrombus formation precedes the 
formation of the multiple sclerotic patches. 
Still another concept regards multiple sclero- 
sis as being due to myelin destruction from 
lipase ferments in the blood stream. By 
some it is believed to be a spirochete infec- 
tion, and by others to be a virus disease. 

Encephalitis periaxialis diffusa, or Schil- 
der's disease, is an extensive demyelinizing 
process characterized by the destruction of 
myelin with the preservation of axis cylin- 
ders. The disease involves entire lobes of 
the brain. Infiltration with lymphocytes in 
the areas of destruction as well as around 
the vessels is often seen. Glial scar forma- 
tion develops later. The short arcuate fibres 
connecting adjacent cortical gyri are often 
preserved. The demyelinized areas involve 
the occipital lobes symmeterically, and may 
extend forward into other parts of the brain, 
or they may involve primarily the frontal 
areas. The disease occurs usually in chil- 
dren, is characterized by a slow, gradual on- 
set, with blindness, often with convulsions, 
and with mental deficiency. 

Allied to this group of encephalitides is a 
disorder recently described as neuromyelitis' 
optica (Devic's disease). This disease is 
characterized by optic neuritis and subjec- 
tive visual complaints, associated with signs 
of involvement in other parts of the nervous 
system. Many investigators regard it as a 
form of multiple sclerosis. 

Perivenous Encephalitis. 

A particularly important group is the pe- 
rivenous enchephalitis, which is classified by 
some with the acute demyelinizing enceph- 
alitides. It is better classified as a separate 
group both clinically and histologically. This 
group of cases is characterized by diffuse 
small areas of encephalitis scattered through- 
out the brain substance, involving chiefiy the 
white matter of the cerebral hemispheres, 
the internal capsules, and the white matter 
in the base of the brain. The cortical gray 
matter is involved to a lesser degree. The 
encephalitic areas show demyelination 
around the venules, with destruction of both 
the myelin and axis cylinders, and with pe- 



rivascular infiltration consisting chiefly of 
glial cells. 

This form of encephalitis has been found 
to occur following vaccination, measles, Ger- 
man measles, pertussis, chicken pox, small 
pox, and mumps. Cases following vaccinia 
have been few in this country, but were ex- 
tremely numerous in Holland, England, and 
Germany a few years ago. The enchephali- 
tis in these cases is accompanied by a sec- 
ondary rise in temperature, and by varied 
clinical signs. There may be an onset with 
convulsions, with hypersomnolence and cra- 
nial nerve paralyses, (abducens or oculo- 
motor paralyses), or with weakness of one 
or more limbs. The mortality in vaccinial 
encephalitis is high (30-40 per cent), in 
measles low (10-15 per cent). The enceph- 
alitic sequelae in measles are apt to be quite 
high, especially in some epidemics. The 
mortality and sequelae following chicken pox 
are slight. Nervous complications may oc- 
cur about twelve days after vaccination, 
about six days after eruption in chicken pox. 
about three to six days after the eruption 
in measles, and on the third or fourth day, 
in German measles. The neurologic signs in 
encephalitis following German measles in- 
clude headache, neck stiffness, attacks of un- 
consciousness, and mental confusion. The 
cell count of the spinal fluid is increased 
(10-200 lymphocytes). 

The diagnosis of encephalitis during one 
of the exanthemata is not difficult, with a 
history of onset of neurological or mental 
signs at varying periods following the rash. 

There is much disagreement concerning 
the causative agent in these cases. Some 
investigators believe the encephalitis is due 
to the agent causing the exanthem, others 
that a virus independent of the original 
causative agent is responsible, and still 
others that the cause is an allergy of some 
obscure nature. The favored hypothesis is 
that the encephalitis is caused by the same 
agent as measles, chicken pox, or the other 
associated exanthemata. It is not possible 
to say, however, that some other virus or 
infectious agent may not be the cause. 
Hemorrhagic Encephalitis. 

The group of cases spoken of as hemor- 
rhagic encephalitis constitute an important 
and well-known group of cases. These cases 
are characterized by discrete or confluent 
petechial hemorrhages found scattered 



January, 1940 



ENCEPHALITIS— ALPERS 



23 



throughout the cerebral hemispheres, or in 
the brain stem. The hemorrhages may be 
few or numerous. They consist usually of 
fresh extravasations around the blood ves- 
sels and within the brain tissue, with de- 
struction of the invaded areas. They are 
found in a wide variety of conditions — such 
as trauma, chronic alcoholism, typhus fever, 
malaria, rheumatic fever, influenza, hemor- 
rhagic diatheses, arsphenamine and toxic- 
infectious conditions of various sorts. In 
alcoholism they are found especially in the 
roof of the midbrain, giving rise to ocular 
palsies and to the sydnrome known as polio- 
encephalitis superior of Wernicke, or Wer- 
nicke's encephalitis. Recent studies tend to 
show that this form of hemorrhagic enceph- 
alitis is the result of a vitamin B deficiency. 
In trauma the hemorrhages may be few or 
numerous, and the same holds true for the 
other causes. The hemorrhagic encephalitis 
following arsphenamine administration 
usually occurs after the second or third in- 
jection. It is usually a very extensive en- 
cephalitis with much brain damage, from 
which recovery is incomplete. Rarely, the 
hemorrhage may involve the spinal cord. 
There is nothing characteristic of the clini- 
cal features of the hemorrhagic encephalitis 
occurring during toxic-infectious conditions, 
but the condition should be suspected when- 
ever cerebral complications occur during 
fevers. Petechial hemorrhages may occur 
from endocarditic or pulmonary emboli. 

The clinical features of the hemorrhagic 
encephalitides are not very well-defined and 
need much clarification. 

Miscellaneous Types of Encephalitis. 

Finally, one finds a number of cases of en- 
cephalitis which are difficult to classify. 
They constitute a miscellaneous group with 
numerous causes and many types of histo- 
logical pictures. 

Chief among them is a group of so-called 
otogenous encephalitis. These cases develop 
secondary to middle ear infection. The 
pathological picture is not clearly defined, 
but it has been described as a non-suppura- 
tive encephalitis, by which is probably meant 
a non-infectious encephalitis associated with 
focal inflammations. The clinical signs are 
those of a focal cerebral lesion, the onset 
being frequently with convulsions. Head- 
ache, mental confusion, and fever may be 
found in this syndrome. The clinical picture 



varies greatly, but the important feature to 
recall is that the process may appear in a 
case with middle ear infection. This type 
of encephalitis is of great practical impor- 
tance, for the problem arises during cerebral 
complications in middle ear infection as to 
whether one is dealing with an encephalitis 
or with brain abscess. There is no question 
that cases of otogenous encephalitis occur 
and that they are best treated by conserva- 
tive rather than by radical neurosurgical 
methods. They may give rise to focal cere- 
bral signs just as does abscess, but there is 
no increased pressure as in the latter. 

Encephalitis has been described following 
B. abortus infection. The brain and me- 
ninges in such cases contain miliary granu- 
lomas. It has been reported also following 
the injection of horse serum. Facial ery- 
sipelas has been found on a few occasions 
to be associated with an encephalitis charac- 
terized by large areas of demyelination in 
the brain. Cases of encephalitis have been 
recorded in gonorrhea. Pneumoconiosis has 
been reported with a complicating encephali- 
tis. A non-suppurative encephalitis has been 
reported following labor. 

Toxic enchephalitis has been reported in 
children, associated with acute infections 
such as otitis media, pneumonia, scarlet 
fever, and septicemia. The clinical picture 
in these cases showed a rapidly developing 
diffuse cerebral involvement, early stupor, 
hyperpyrexia, and death in three or four 
days. It is quite probable that a toxic en- 
cephalitis of this type, with vessel damage, 
but without evidence of inflammation may 
occur in adults during high fevers or severe 
toxemias. 

Summary. 

These random observations serve only to 
emphasize the many forms of encephalitis 
which may be encountered not only in neu- 
rology but in general practice. The purpose 
of working classifications is to clarify one's 
ideas so that some degree of order may de- 
velop from a confused or complicated prob- 
lem. This I believe is the main purpose of 
such a classification as I have outlined. If 
it helps to insert in its proper slot some 
obscure case of encephalitis, and by so doing 
defines more specifically the diagnosis of en- 
cephalitis it has done all that can be hoped 
for in such a discussion. 



24 



NORTH CAROIINA MEDICAL JOURNAL 



January, 1940 



COORDINATION OF PUBLIC HEALTH 

AND RELATED AGENCIES* 

Carl V. Reynolds, M.D., 

Secretary and State Health Officer 

The world today seems to be in a state 
of flux. There is great unrest in our 
religious, social and economic structure. It 
seems that the world has forgotten the gold- 
en rule and that this rule has been exchanged 
for selfish individualism, with the result that 
we are at one another's throats. There is 
good in the worst of us, and in my opinion 
we can capitalize on this good at a round 
table conference by discussing frankly our 
objectives and ironing out our differences. 
We can, through consultation, develop a wise 
program that will contribute to the advan- 
tage of all. 

In this day of rapid communication, one 
can no longer live unto one's self. City, 
county, state and inter-state boundaries are 
today so closely tied that our population is 
one large community, and it is essential to 
the welfare of the whole that it be treated 
as such. 

Since the Federal and State governments 
began to assume their part in supplement- 
ing county and city funds for the establish- 
ment and maintenance of public health units, 
and have established policies under which 
counties, cities and districts can participate, 
advancements have been most encouraging. 

Since 1933, we have grown from 38 full- 
time county and district health organizations 
to 76 in 1938. Ninety per cent of our popu- 
lation is now being ministered to by full- 
time, qualified personnel through county 
health agencies. 

I have only to remind you of the past for 
you to realize the great advancement we 
have made through governmental, state, city 
and county cooperation in building a health 
program that will accrue to the everlasting 
benefit of the whole people. 

Our health family of 580 woi'kers is fast 
becoming a recognized and essential unit of 
our social structure, and its influence and 
effectiveness is being recognized and appre- 
ciated as never before in history. 

There are many problems in a community 
so closely allied that their interests can be 
best served through an interchange of ideas 



*Read before the North Carolina Public Health Association, 
Greensboro, N. C, May 1, 1989. 



from experts in each field. This interchange 
of ideas would pi-event duplication, bring 
about a better understanding, and enlarge 
the field of usefulness of all agencies. 

May we consider the relationship between 
the public health administration and the 
practicing physician. The passage of the 
Social Security Act, the La Follette-Bul- 
winkle Syphilis Bill, State Aid to Counties, 
Funds for the Erection and Maintenance of 
Tuberculosis Sanatoria, the Industrial Hy- 
giene Act, and other aiding acts — namely: 
"A Bill to Prevent Diphtheria in Children 
and to Eradicate the Disease" ; "Prenatal 
Serological Test Law"; "An Act to Require 
Physical Examination Before Issuance of 
License to Marry"; "An Act Requiring Ex- 
amination of Domestic Servants", etc. — is a 
recognition that the government has a defi- 
nite responsibility in the prevention and cure 
of disease and the preservation of health. 

These new responsibilities are a challenge 
to the ingenuity of the medical profession, 
and all such activities should be directed, 
supervised and controlled by the best quali- 
fied medical personnel available. 

We are at the threshold of a new era, and 
we can see the dawn of a new day, if only 
we will seize the opportunity to guide, direct 
and control policies. All of us recognize 
that health security is of basic importance 
to human happiness and well-being. 

After long controversial discussions as to 
the merits or demerits of federal participa- 
tion, the House of Delegates of the American 
Medical Association, in special session held 
in Chicago, September 16, 1938, to consider 
the National Health Program and establish 
the policies of the Association with regard 
to it, recommended : 

Expansion of public health services, as 
related to the control of certain infectious 
diseases, maternal and infant welfare, and 
similar projects, with the definite under- 
standing that the need be established and 
that they be efficiently handled and economi- 
cally controlled. The House of Delegates 
approved the principle of hospital insurance 
and the principle of cash indemnity insur- 
ance for meeting sickness costs; recognized 
the need for complete medical services to 
the indigent under local control, and for 
state aid in poorer communities. 

In short, the House of Delegates approved 
certain recommendations of the interdepart- 



January, 1940 



COORDINATION OF AGENCIES— REYNOLDS 



25 



mental committee but reiterated its firm op- 
position to any compulsory sickness insur- 
ance plan. The Association has not aban- 
doned any of its policies for the maintenance 
of professional standards. 

It is further stated in an editorial in the 
A.M.A. Journal, September 24, 1938, that 
"the meeting of the House of Delegates had 
a most wholesome effect in allaying doubts 
and fears among the medical profession as 
to the position of the American Medical 
Association in relationship to recent propa- 
ganda that has been widely circulated in 
this country. The unanimity of expression 
and action again indicated that these repre- 
sentatives of 110,000 American physicians 
are able as a democratic body to express the 
wishes of the vast majority of the medical 
profession in this country and to speak with 
one voice for them." 

We cannot accomplish anything through 
continued agitation. We should be demo- 
cratic enough to follow the advice of the 
vast majority of our profession. If we could 
onljr admit this point we should set about 
to submit a workable plan that will retain 
our individuality and give the patient the 
right to choose his medical or surgical ad- 
vi.ser. 

This can be accomplished if the program 
control is placed where it should be, within 
the ranks of the medical profession. 

I believe that we can accomplish nothing 
through rebellion. We must recognize and 
accept the truth. 

To regiment medical service is to destroy 
its efficiency. 

To preserve the present standards of 
medical service and promote its continued 
growth, we must foster individual attain- 
ment and recognize it by a compensation 
commensurate with its importance, at the 
same time realizing that selfish individual- 
ism is hazardous and that mass protection 
is necessary to social security. 

There must be a correlation and coordi- 
nation of the activities of the practicing 
physician and public health administrator 
that will best serve the whole people. In 
this manner, we can "make progress serve 
us instead of enslave us". 

Education. — The physician, the dentist, 
the nurse, and the nutritionist have a tech- 
nical knowledge and are trained therapeu- 
tists, but most of them are not trained in 



pedagogy. The school teacher, on the other 
hand, does not have the technical knowledge, 
but is adequately trained in pedagogy. 

With this in view, there is, at this time, 
a plan whereby the facilities of the State 
Board of Health and the State Board of 
Education will be integrated in the develop- 
ment of a unified health service in the public 
schools of our state — by setting up jointly, 
as an initial step, a coordinating agency. 

In this co-ordinating agency it is under- 
stood and agreed that there is to be full co- 
operation between the two agencies in re- 
gard to health and physical education, but 
that ultimate authority in instructional mat- 
ters shall remain with the State Department 
of Public Instruction. 

It is understood and agreed also that with 
regard to technical matters of sanitation and 
health services — such as clinics, physical ex- 
aminations by physicians, follow-up work 
for the correction of defects, and immuniza- 
tion programs — there is to be full coopera- 
tion between the two agencies, but ultimate 
authority in such matters shall remain with 
the State Board of Health. 

The plan presented in the proposal, there- 
fore, is designed to correct defects in the 
organization by bringing about more eflfec- 
tive team work between the two agencies in 
the formulation and execution of a school 
health program which will meet more ade- 
quately the needs of the people. 

The importance of such a relationship can 
be realized when we consider the good that 
can be accomplished by an army of 24,000 
qualified teachers instructing 900,000 chil- 
dren, who will in turn instruct their parents. 

Welfare. — It is generally recognized that 
health and education are basic in establish- 
ing social and economic security. It is equal- 
ly appreciated that there are allied essentials 
in perfecting this ideal — environment, cloth- 
ing and housing. This would immediately 
suggest a correlation of health, education 
and welfare activities. 

At this time, through the State Commis- 
sioner of Public Welfare, we attempting to 
establish a harmonious working relationship 
between health and welfare agencies. State- 
ments of the duties and responsibilities of 
the County Superintendent of Public Wel- 
fare, and an outline of the Public Health 
practices and services approved by the State 
Board of Health were sent out for study. 



26 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



This communication suggested that the 
Superintendent of Public Welfare and the 
local Health Officer discuss together any 
points which were not thoroughly under- 
stood at the time. 

Agrindture. — Walter B. Cannon, Profes- 
sor of Physiology, Harvard University, says : 
"In the United States the population has 
changed from about 60 per cent rural to 60 
per cent urban since 1900". This is a signifi- 
cant trend for which there must be a reason. 
People do not leave the country because they 
cease to love it. They go in search of the 
labor-saving devices and modern conveni- 
ences which contribute to an easier and a 
"more abundant life". 

Low birth rate in the urban population is 
to some extent compensated to the cities by 
the higher birth rate of the rural popula- 
tion. This condition can only be changed 
and improved through an interchange of 
ideas with state and county agricultural of- 
ficials. Our object would be to have a uni- 
fied agricultural program connected with 
other allied agencies. 

We have learned that an impoveri.shed soil 
means impoverished foods. If the soil lacks 
essential food elements, the foodstuffs grown 
on it may show a similar deficienc}'. We 
know that foods given in proper amounts 
and coming from proper sources will contain 
the proteins, carbohydrates, fats, minerals 
and vitamins necessary for the body's physi- 
cal needs and for developing protective 
forces that will resist diseases. 

Medical science is far in advance of the 
public's willingness to take advantage of it. 
There must be a reason. Ignorance and in- 
difference both play a part ; poverty plays a 
part. But, to my mind, ignorance of the 
basic essentials of our body requirements is 
the outstanding obstacle. 

Health education is needed to combat mis- 
conceptions, misinformation, and careless- 
ness that lead to improper selection and 
preparation, or to contamination of these 
essential foodstuffs. 

These brief statements will make us realize 
and appreciate the great advantage that 
could accrue from conferences among such 
allied agencies. 

May I suggest a plan for your careful con- 
sideration and mature judgment? 



Plan. — We have our people needing medi- 
cal care in one group. 

We have the medical profession to admin- 
ister that medical care in another group. 

We must have the best available mind to 
direct this most important and vital ele- 
ment in moral, mental, physical, social and 
economic welfare. 

To whom shall we turn for this service? 

The unanimous decision would be that the 
medical mind is the better qualified. 

This being admitted, may I present to you 
a Board of Directors, namely : Secretary and 
Chairman of the Executive Committee of the 
State Medical and Dental Societies; repre- 
sentatives from County Medical and Dental 
Societies; governmental representatives; 
State Health Oflicer; County Health Officers; 
City Health Officers ; representatives from 
the departments of Public Welfare, Agricul- 
ture, Home Economics, and Public Instruc- 
tion, from Parent-Teacher Associations, 
from Hospital Boards, from the Institution 
for the Blind, from mental hygiene groups, 
and from civic clubs. 

By this board ways and means are to be 
devised to render service to its citizenry in 
preventive medicine, medical and surgical 
care, maternal and child hygiene, crippled 
children and care for the insane and blind. 

North Carolina has 100 counties. Would 
it not be an advanced step to organize 100 
conference committees composed of repre- 
sentatives from all interested agencies to 
study out problems and formulate plans to 
solve them? 

Yes, we have done much, but the half has 
not been done ! The determined public has 
set about to do it and they should have 
leadership. Organization conferences will 
prevent misunderstadings among those who 
have an honest purpose in view. 

An honest discussion will bring forth a 
sane decision, and to my mind, it will pre- 
vent the regimentation of medical men. It 
will retain the individual initiative and re- 
sourcefulness, and merit will be awarded 
commensui'ate with its attainments. Quali- 
fications will be the standard in selection and 
not political favor. 

A democracy of allied agencies with a 
continuity of purpose, dedicated to service, 
is the an.swer to the world's health, educa- 
tional, social, and economic problems. 



January, 1940 



GESTATIONAL TOXEMIAS— HARDEN 



27 



RECENT STUDIES IN THE CARE OF 

THE LATE GESTATIONAL 

TOXEMIAS 

Boyd Harden, M.D. 
Burlington 

The care of the late gestational toxemias 
resolves itself into a consideration of (1) 
those changes which occur in the maternal 
constitution in so-called normal pregnancy ; 
(2) the appearance of those factors which 
transform an uncomplicated gestation into a 
pathologic state threatening the well-being, 
if not the life, of both mother and infant; 
and (3) the adjustment of the maternal con- 
stitution to meet compatibly the demands of 
reproduction. 

The mechanisms of the profound changes 
which occur in the maternal constitution in 
so-called normal gestation are imperfectly 
understood. The age at which the pregnancy 
supervenes has an influence on the course of 
reproduction. The nutritional demands of 
the fetus, and the disposal of its waste pro- 
ducts place increased demands on the mater- 
nal host. Normal pregnancy is associated 
with an increase in basal metabolism which 
is proportional to the combined surface area 
of mother and fetus. A demand for in- 
creased minute volumes, at the site of im- 
pregnation, may be satisfied in several ways : 

(a) Additional erythrocytes may be formed. 
Yet, normal pregnancy has been shown to 
exhibit three distinct types of anemia: the 
physiologic type, so-called, characterized by 
a progressive increase in anemia up to the 
third trimester when an abrupt rise in hemo- 
globin and erythrocytes occurs ; the hypo- 
chromic, or chlorotic type, characterized by 
a lowering of hemoglobin and associated 
with hypoacidity; the macrocytic type, 
characterized by progressive anemia and 
complete post-histamine gastric anacidity. 

(b) The cardiac output may be augmented 
by an increase in the venous return to the 
heart, and this in turn may be influenced by 
an increase in the cardiac rate. Cardiac 
hypertrophy may participate in the mechan- 
ism of volume increase. The greater systol- 
ic delivery of blood results in greater pulse 
amplitude and increased pulse pressure, 
which must be counterbalanced by vasomotor 



control to prevent elevation of blood pres- 
sure. Yet, the majority of pregnant women 
have been shown to exhibit capillary spasm. 

The chief changes in the glands of internal 
secretion in normal pregnancy concern those 
organs whose functions govern metabolic 
rate and the factors of growth and develop- 
ment. The anterior lobe of the pituitary, 
the thyroid, the parathyroids, the cortex of 
the adrenals, and the ovary present the 
greatest gross and microscopic evidence of 
increased activity. 

The constitutional reserves of protein, fat, 
carbohydrate, inorganic salts, water, and 
vitamins, and the metabolic efliciency of the 
woman as she enters the responsibility of 
reproducing her kind are problems for 
patient and meticulous research. The re- 
sponse of the maternal constitution to the 
demands of gestation is influenced by such 
factors as physical habitus, malnutrition, 
disturbed function of the glands of internal 
secretion, disease of vital organs, previous 
acute illnesses with incomplete recovery, in- 
tercurrent infections, foci of infection, fever, 
and drugs. 

Nitrogen reserves at the beginning of 
pregnancy are not the same in all women. 
The retention of nitrogen is out of propor- 
tion to the fetal need, the enlargement of 
the organs of generation, the increase in the 
daily needs of the maternal host, and the 
retention of nitrogen begin early in gesta- 
tion. This positive nitrogen balance prevails 
in spite of lowered total plasma protein, 
with no evidence of retention of nitrogenous 
waste products in the blood and with de- 
creased total nitrogen excretion and changes 
in the nitrogen partition in the urine. It is 
reported that one patient, in the last 21 
weeks of gestation, stored 446 grams of ni- 
trogen. After parturition and 53 days of 
lactation, 250 grams of nitrogen were still 
held in reserve. 

Reports vary as to the storage of iron, 
sulphur, calcium and phosphorus in normal 
pregnancy. There is about a 5 per cent 
lowering of the total serum base, unex- 
plained on the basis of fetal needs or of 
organic acid excess. 

There is doubt about the interpretation of 
the blood sugar content of women in uncom- 
plicated gestation. 



28 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



Normal pregnancy is associated with a 
marked rise of about 30 per cent in the total 
lipoid content of the blood. 

The moot questions in normal pregnancy 
have been deliberately brought into this dis- 
cussion to emphasize our inability to reach 
a solution of a more difficult problem until 
we have laid the ground work for its 
analysis. 

The premonitory symptoms and signs of 
convulsive seizures are outlined in any good 
text book of obstetrics and have been specifi- 
cally summarized from a series of patients 
in the Elizabeth Steele Magee Hospital in 
Pittsburgh in a previous monograph'". 
There is no point in enumerating material 
which is alreadj' familiar. 

The purpose of this summary was to try 
to establish one finding, which in our ex- 
perience at least, is peculiar to every patient 
whose pregnancy culminated in pre-ec- 
lampsia or eclampsia. We were unable to 
find such common denominator in a review 
of more than 39,000 papers, directly or in- 
directly related to this problem. At this 
stage of our study there was admitted to our 
wards a patient in the eighth month of ges- 
tation, with a blood pressure of 244/146, 
with headache, scotomata and transient 
blindness; tinnitus; formication and numb- 
ness of the extremities ; sore throat without 
apparent cause; heartburn: dyspnea; pre- 
cordial distress; lancinating pain in the 
epigastrium; nau.sea and vomiting; deep, 
dull, boring, pain in the right upper quad- 
rant; backache; obstipation: frequency, urg- 
ency, burning and pain on micturition; ex- 
coriating leucorrhoea; a massive generalized 
edema; and an inordinate fear of impend- 
ing death. Her red cell count was 1.800,000. 
and her hemoglobin was less than 20 per 
cent by the Haden-Hauser hemoglobino- 
meter. Her urine boiled solid. A twenty- 
four hour specimen of 128.5 cc. showed a 
quantitative protein content of 1.5.5 grams. 
It occurred to us that no human constitution 
under any condition of life could long with- 
stand the dissipation of so vital an element 
as protein to so profound a degree without 
serious or fatal consequences. 

In coming to this conclusion, we di.scovered 
one factor which, in our experience, has 
occurred consistently in the toxemias of 



pregnancy both early and late. This factor 
is marked nitrogen deficit. A regime was 
instituted to control this deficit. Patients 
were required to have at least eight hours 
of rest each day, foci of infection were 
eliminated wherever possible, elimination by 
bowel was secured by the use of milk of 
magnesia or soap suds enemata, and each 
patient was given a sufficient caloric intake 
to satisfy her basal needs plus the require- 
ments of the infant. When a patient was 
unconscious, or unable to take food by mouth, 
intravenous glucose was given in 10 to 25 
per cent concentration in sufficient quanti- 
ties to approximate the individual's caloric 
requirements. The diets contained the basic 
protein requirement of the maternal host, 
plus the requirement of the infant, and the 
protein lost in the urine. 

As proof that our diets supplied the basic 
nutritional demands for protein of the fe- 
male body in jiregnancy, the following evi- 
dence is presented : 

Thirty-six patients with typical pre-ec- 
lampsia and 42 patients with typical ec- 
lampsia referred to the hospital for treat- 
ment were placed on these diets, which were 
calculated from the DuBois metabolism 
chart. The average caloric requirement and 
the average diet given to each group is pre- 
sented in Chart I. 

Chart T. 

Pre-Eclampsia 

Ai'eraQ^ Jtitake in Gravis 
Arq.Ht. Arn.ni. Avg.Alie Protein Fat Car. 

l.'.5..^0 cm. 80.3 kilo<3 29.9 yrs. 82 61.1 218 

<l\ iriK DiinoiS ('ll\KT: 

I.^.^.-lii cm. mecls ho..-! kilos at 1.8 sijiuire meters. 

At 2!i.9 ycirs of nge the female requires 87 calories per 

sfjuare metep* of su^f.^ce area per hour. 
1.8 square uieters X 37 calories y 21 hours = 1598.* 
calories ns the hasic caloric requirerueiit of the mother. 
DIKT.ARV VALUES: 

Protein h2 crus. X * cal. per srani =r .128.00 cal. 

Fat (11.1 pms. X 9 cal. per gram = 549.91) cal. 

Carbohydrate 218.0 puis. X * cal. per graiu = 872.00 cal. 



.\dministere(l in diet 1719.90 cal. 

Eclampsia 

Average Intake in Grantt 
A If,. HI. Aiij.tVI. Aru.Ate Protein Fnt Car. 

1.11.1 cm. 80 kilos 26.6 yrs. 69.1 61 209 

ON TUF. l)ullOI.<; fHART: 

111.1 cm. meels so kilos at 1.8 square meters 

.\t 26-0 years of ace the female requires 37.2 calories per 

square meter of surface area per hour. 
1.8 square meters- x 37.2 calories v 21 hours — 1607.0 1 
calories as the hasic caloric rcquireiuent of the luother. 
Iill-.TAHV VALUE.S: 

Troteiti 69.1 Knis. x 1 cal. per cram = 277.60 cal. 

Fat 61.0 pnis. X 9 cal. per pram ^ .119.00 cal. 

Carhnln (Irate 209.0 gms. X 1 cal. per gram^ 836.00 cnl. 



(I) Harden. Boyd: A Study in Prc.F.elampsta and Eelaiu|i> 
friiverslty of Pittsburgh Prcs.s, 1936. 



.■Xdministeretl and consumed in diet 1662.60 cal. 

After stabilization on the diets the fate 
of the protein in the diet was determined as 
follows : 

The urinary non-protein-nitrogen was de- 



January, 194d UROLOGICAt, PROCEDURES— McKAY 29 

termined, this figure representing the nitro- I think Dr. Watson will be interested to know that 

o-pn tVint was nrtnallv mptahnliypd hv the ^^'^ ^''™' ^* ^'^^^ Hospital at least 40 per cent of 

gen tnat was actually metaooiizea oy me toxemias in our total obstetric patients. We are 

body. This multiplied by 6.25 was converted working on it and we hope some day to be the ones 

into protein. To this was added the amount t° '^fj"^ °"}- "^me in the niche which I understand 

. , . . . ii • J J? the University of Chicago has reserved for the name 

of protem appearing in the urine and teces of the man who discovers the cause of eclampsia. 

and the total of these three subtracted from It seems that here in North Carolina where we have 

the protein intake. The difference, when ^o^mue^hto^™ one of you gentlemen will discover 

positive, represents stored protein, and when I enjoyed Dr. Harden's paper very much. I think 

negative, represents a protein deficit. ''^ *'?%'*°"®*u ^^^.f u'^^^l u '^"■^''i ^""^ ^H "i?""" 

°, 'xT • ,1 li J? ^1 graph from the Pittsburgh Hospital is outstanding. 

Chart II gives the average results of these i think it was published in 1933. I wish all of you 

determinations on the two series of patients, could read it. 

showing in both groups a definite and con- 

siderable storage of protein. NEW UROLOGICAL PROCEDURES OF 

GENERAL SURGICAL INTEREST 
Chart II. 

Protein Metabolism HAMILTON W. McKAY, M.D. 

(Average of 42 eclamptic patients) CHARLOTTE 

Gnu. Protein A few new procedures with which the 

Lost in ""cet IIII-IIIIII""!!"!!"!"!"!-!! nisi urologist is familiar and which he uses daily 

.Metabolized (d.o X Trinary N.P.N.) j8^ ^^,jjj ^^ discussed briefly. Certain phases of 

Total (lost and metabolized). — _......_- «4.iB major Operations and some minor procedures 

Tota" (?os1'*and'Wia"boUzed)I"""II""~-i; S'iiS will be Considered. New approaches to com- 

Amouiit stored "Tij Ij^t old Complications — such as infection and 

Protein Metabolism hemorrhage — will be explained. No prob- 

(Average of 36 pre-eclamptic patients) lem will be dealt with that should not be of 

lost in urine _ Gms. Protein yjj-^j interest to a mixed medical audience. 

Lost in feces 12.75 

.Metabolized (6.2.1 x Urniary N.r.N.) 4a.JS Prostatic RCSectlOn 

Total (lost and metabolized) flO.88 „ „ ., , . , . . , . 

Given in diet 82.00 ^fle of the most important major urologi- 

Totai (lost and metabolized) J0.88 cal Operations discussed in recent years has 

Amount stored si.is been & reviving of the old punch operation. 

In a period of seven years, 704 patients ^he modern and well known operation popu- 

.,, 1 , ... , , . A -n. A larized as prostatic resection has been made 

with late gestational toxemias were admitted -i,, i, ^i. • i- • c 

. , j; 1. 1 1 ] possible by the inventive genius ot many 

to our wards, no one of whom developed con- ,..,., ^ . i. • xi. 

, . . J ii,- • i iu urologists, by the great improvements in the 

vulsive seizures under this regime; yet the ^ ^ ■ c ■ t * j u 4.1, 

, . ■, ,. .-i^i. iu manufacturing of instruments, and by the 

number of eclamptic patients referred to the ,, j , ■ 5 e 1.1. ^ ^ ■ ,/ „„a 

, .,,. ,. ■ ^ ■ ,^. added knowledge of the electric current used 

hospital in convulsions maintained the same , ,-, j. .^- , , i- xt„ 

. .J . ^, •, i, i ■ both for cutting and coagulation. No oper- 

incidence in the community as that previous ^^.^^^ ^ professional experience has 

to the adoption of this regime. ^^^^ ^^ enthusiastically received either by 

Conclusion : It would appear that protein j^e medical profession or by the laity as has 

stabilization has dealt with fundamental prostatic resection. It is quite natural that 

factors in the prevention of eclampsia. misinformation has been disseminated 

Discussion among the doctors throughout the country 

bv the commercial instrument houses recom- 

DR. W. L. THOMAS (Durham): Mr. Chairman ,. ■■ , . ,„ „ ,, .. „ „„„;„„„ „„„<, 

and Members of the Society: It would seem that mending and trying to sell the various pros- 

Dr. Harden is trying to show us here, not the cause tatic resection machines, and that early ad- 

of pre-eclampsia and eclarnpsia, but a method of locates of this type of operation for the re- 

preventing and treating it — that is, the protein »">'"'-^'= "'^ " jf f 

stabilization of a patient. moval of a portion of the prostate were over- 

We found that the dietary deficiencies and toxe- enthusiastic. Often a referring doctor will 

mias in North Carolina seem to go hand in hand. , . i' j. -n, i„ , „„„;^,,„i ,,,.;„,:, 

We see more patients who have ptllagra from cer- send in a patient With large residual uune, 

tain districts than from others. We also seem to severe infection, or what not, asking that 

see more toxemias from the same districts. ^ j^j prostate as casually as he would 

We have a feeling that a long-standing diftavy -^i^^^^^' f 

deficiency, perhaps not of one generation but of ,_ „ , ^ , c • » .1 «< .ii„„i 

several generations, probably accounts for the great *Sty'"'or'ihe"'staU™o"t' N° rth^CarllSr Bermuda 'c^ 

amount 01 toxemia that we have. Ma; 13, int. 



30 



XORTH CAROLINA MEDICAL JOURNAL 



January. 1940 



ask for a cystoscopic examination. If this 
is true of the medical profession — as it sure- 
ly is — what must the laymen think about it ? 
They have even been told that they do not 
have to be cut ■ — • the "selling surgeon" or 
"commercial surgeon" meaning to convey the 
idea to the patient that he cannot see the 
cut; so the patient comes to the doctor ask- 
ing for a certain type of operation which he 
believes is nothing more than looking into 
the bladder and by some mystic process melt- 
ing the prostate away painlessly, without dis- 
comfort afterwards and with no time spent 
in the hospital. 

What is the truth about this remarkable 
operation? Every urologist now realizes 
that prostatic resection is a highly special- 
ized technical operation done with great 
danger in inexperienced hands and accom- 
panied by many complications even in the 
hands of the experienced operator. No one 
who has done very many resections can 
doubt this statement. We have the same pit- 
falls in prostatic resection that we have in 
any other method of prostatic surgery — 
namely, infection and hemorrhage. 

Have we improved in our method of deal- 
ing with infection of the prostate? Surely 
we have. Patients with no residual urine or 
with little residual urine are operated on as 
soon as the general phj-sical and other neces- 
sary examinations have been done. No re- 
tention catheter is placed in the bladder, and 
no long period of preparation is thought 
necessary. In this special group neo-pron- 
tosil is a valuable drug to give both before 
resection and after resection in order to pre- 
vent infection or to limit infection already 
present. 

Our methods of dealing with hemorrhage 
have also improved. Four procedures are 
worthy of note: (1) The injection of pitui- 
trin'*' by a long needle through the resecto- 
scope directly into the prostate gland in the 
large succulent prostate reduces hemorrhage 
during the operation, and there is no evi- 
dence that there is bleeding following opera- 
tion. (2) The use of injections of theelin'"' 
in the preparation of patients for prostatic 
resection has been useful in our hands, and 
there appears to be less bleeding at the 
actual time of resection. (3) The use of 



: Letters of the Urologists Letter Club 

of the United States, Vol. I and II, 1938 and 
1939, Burgess Publishing Company. 



the combined retention catheter and Foley 
bag"', or what is now known as the Foley 
hemostatic bag, has been a godsend to us in 
our prastatic work. (4) The irrigation**' 
with 20 per cent Karo syrup through the 
Foley hemostatic bag is of unquestionable 
value in the cases that are inclined to bleed 
slowly or to ooze. This form of irrigation 
prevents or limits the formation of clots in 
the bladder. 

Urinary Infections 

In the not far distant past we were ac- 
customed to treating pyuria without con- 
cerning ourselves with the organism which 
was the etiological factor. In the last two 
or three years our whole conception of 
treating urinary infections has completely 
changed. The very first thing we want to 
know is the offending organism ; then we 
prescribe the drug or diet — or both — which 
will either inhibit the growth of this partic- 
ular organism or render the urine sterile. 
Of the new methods of treating urinary in- 
fections, the ketogenic diet, mandelic acid, 
sulfanilamide, sulfapyridine, and neo-ars- 
phenamine have done more to put the treat- 
ment of urinary infection on a scientific 
basis than all the former theories and treat- 
ments combined. 

A great many of the severe infections of 
the kidney are due to the staphylococcus, 
and this organism is of great importance in 
stone formation and the growth of stones. 
Especially is this true in recurrence of cal- 
culi post-operatively. Some of the new drugs 
act favorably on some strains of cocci, but 
the coccal infections still present the out- 
standing problem and the one which we hope 
will continue to be worthy of the best re- 
search. 

Intravenous Urography 

This procedure is one of the most valua- 
ble single aids which have been discovered 
in recent years. It is a lamentable fact that 
few urologists, and still fewer roentgenolo- 
gists and other physicians who have x-rays 
take advantage of this valuable diagnostic 
procedure. They do not seem to appreciate 
the great importance of the preparation of 
the patient. Lack of preparation of the 
patient means the useless injection of an ex- 
pensive drug and the added cost and waste 

1. Foley, Frederick; Hemostatic Bag Catheter, J. 
of Urol. 38:134, 1937. 



January, 19-40 



UROLOGICAL procedures— McKAY 



SI 




Figure I: Adenomatous hypertrophy (grade IV) 
Numerous spheroidal bodies resembling bunch of 
grapes. Best removed by open operation. 

Figure III: Recent devices for control of post- 
operative hemorrhage in prostatic surgery. Brake 
bag. Various sizes of Foley's hemostatic bag. 

of one or more x-ray films. As a function- 
al kidney test, intravenous urography prob- 
ably tells LIS more in a graphic way than any 
common "work test". 

New Mcihodx of Treating Hydrocele 

The recent injection methods to obliterate 
the hydrocele sac advocated by Dr. George 
Livermore'-', and the injection of quinine 
hydrochloride and urethane advocated by 
Louis Raretz'-" are of great importance to 
all urologists and surgeons. 

2. Livermore, George: Livermore Method for Re- 
lief of Hydrocele, J. of Urol. 39:418, (April) 
1938. 

3. Baretz, Louis: Cure of Hydrocele by Injection, 

N. Y. J. Med., 38:489-493, (April) 1938. 



Figure II: Adenomatous hypertrophy (grade IV) 
150 grams. Best results obtained by prostatec- 
tomy not resection. 

Figure IV: Tissue extract with syringe to forcibly 
illustrate its practical use in many forms of 
kidney colic and ureteral spasm. 

Figure V: Intravenous anesthestics well adapted to 
minor urological surgery in office or hospital 
practice. 



Interstitial Cystitis (Runner's Ulcer) 

Interstitial cystitis probably produces the 
most distressing symptoms and acute and 
chronic suffering of any disease of the blad- 
der. Certainly our knowledge of both pal- 
liative and curative methods at the present 
time is very much limited, and any drug or 
procedure which will give the patient com- 
fort is worthy of a trial. Used purely on an 
empirical basis, neo-arsphenamine, given in 
Gm. .3 or Gm. .4, six to ten doses, has oc- 



32 



NORTH CAROLINA MEDICAL JOURNAL 



•T;imiaiy, 1940 



casionallj- produced noteworthy results. The 
use of alcresta ipecac (Lilly), giving six to 
ten tablets at bedtime, has produced an oc- 
casional brilliant result. We are at the pres- 
ent time treating two patients with these 
drugs and have noted great improvements. 
Intravenous Anesthesia 

Surely the urologist, of all specialists, 
should be most interested in anesthesia. In 
the intravenous injection of pentothal sodium 
he has an anesthetic which is easy to ad- 
minister, is practically without danger if 
carefully administered, and which should 
prove a boon to the urologist and a blessing 
to his nervous and apprehensive patients. 
One cc. of this drug puts the patient to sleep 
in ten seconds, and he awakens promptly 
without ill effect. 

Tissue Extract No. 568 (S&D) (^> 

From the beginning urologists have been 
trying to find a drug which will rela.x the 
ureter and produce no untoward effects. The 
injection of 2 cc. to 4 cc. of the I'esidual 
solution after insulin has been precipitated 
has proven very valuable in our hands. In 
cases where we deside to remove a ureteral 
stone in the lower third of the ureter by 
operative cystoscopy, in facilitating the pas- 
sage of instruments when spasm exists, and 
in the dilatation of strictures, we have found 
this drug very valuable. 
Post-Operative Routine (Calculous Disease) 

Every urologist looks forward to the day 
when he can with certainty remove a cal- 
culus or calculi from any portion of the 
urinary tract and assure the patient that 
he will not have recurrence. It is both em- 
barrassing and distressing to the urological 
surgeon to remove a stone from the kidney, 
ureter, or bladder, and have the patient re- 
turn, sometimes in an unbelievably short 
time, with another stone. The past few 
years have added much to our knowledge of 
preventing stone formation by the eradica- 
tion of focal infection, the elimination of 
stasis, the correction of metabolic errors, 
and the correction of vitamin deficiency. 
The taking of plain radiograms and intra- 
venous urograms before the patient is dis- 
missed from the hospital is now considered 
necessary. That dietary adjustment is ab- 
solutely essential in the plan of preventing 
re-formation of stones is now accepted. The 

4. Carroll & Zingale: Effect of Pancreatic Tissue 
Extract on the Ureters, S.M.J. 3:233-236, 
(March) 1938. 



following facts should be noted: (1) Change 
of P" by diet depends on (a) analysis of the 
stone; (b) P" of urine from the diseased 
kidney. (2) No single diet can be applied to 
all patients; individual adjustment is of 
great value. (3) If the calculus is composed 
of uric acid or cystin, the food should be 
purine free. (4) If the calculus is com- 
posed of oxalates, foods rich in oxalates 
should be restricted. (5) Operative removal 
of stone is but one phase in the management 
of this disease. 

Renal Mobility 
Dr. Elmer Hess'^' of Erie. Pa., has em- 
phasized mobility of the kidney and has 
stressed the importance of establishing a 
normal position and normal movements of 
the kidney to compare with abnormal posi- 
tions and movements as an aid to diagnosis 
in difficult conditions — as, for example, peri- 
renal abscess and sub-diaphragmatic abscess. 
When an understanding of the normal and 
abnormal mobility of the kidney in health 
and disease has been reached, many difficult 
problems of a clinical nature will be more 
easily solved. 

5. Hess, Elmer: Renal Mobility, J.A.M.A. 110: 
1818-1823, (May 28) 1938. 



CLINICAL EXPERIENCE WITH 

SULFAPYRIDINE* 

W. A. MacCOLL 

Durham 

One year ago this month sulfapyridine 
made its appearance. Since this time it has 
established itself as a near-specific in the 
treatment of pneumonia, and as a valuable 
drug in certain other types of infections. 
For the past six months the drug has been 
under observation at Duke Hospital, and the 
present report is a presentation of our ex- 
perience, together with the results which 
others have obtained elsewhere.! 

Sulfapyridine is dispensed in 0.5 gram 
tablets or in powder form, and is adminis- 
tered orally. The drug itself is soluble only 
one part in one thousand, which renders it 
impractical for intravenous or subcutaneous 
use; the soluble sodium salt which recently 
made its appearance has not yet received 

*Krom the Department of Pediatrics. Duke fni\ersitv Scliool 
of Medicine and Duke Hospital. Read Itefore the Bermuda 
meeting of the Medical Society of the State uf North Carolina 
May 10. 1939. 



^The sulfapyridine has been generously supplied by Merck 
and Company of Rahwsy, New Jeraey and the Caico Com- 
pany of Bound Brook, New Jersey. 



January, 1940 



SULPAPYRIDIN'E— MacCOLL 



33 



suflkient trial for evaluation. (Recent re- 
ports from Johns Hopkins Hospital are quite 
favorable. Ed.) Sulfapyridine is absorbed 
rather readily from the intestinal tract, 
reaching an effective level in the blood 
stream within five to six hours. It is con- 
jugated in the body in about the same 
proportion as sulfanilamide, and excreted 
through the urine. 

Dosage of the drug has not been standard- 
ized, owing, perhaps, to variation in absorp- 
tion and excretion. Many schema have been 
drawn up, but the necessary modifications 
in these to meet individual demands have 
rendered them of little value except as basic 
schedules to be varied according to such 
factors as degree of illness, tolerance to the 
drug, therapeutic response, or the appear- 
ance of complications. Our basic schedule 
has been as follows: 

Under 1 year of age 1 gram daily 
1-2 yeans of age 2-?> grams daily 

Over 3 years age 3-5 grams daily 

given in divided doses at four or six hour 
intervals. Both a large and a small initial 
dose have been tried. We have noticed little 
difference in the effect, although others feel 
that the large initial does (one half the cal- 
culated daily amount) is warranted in order 
to assure a high initial blood level, and to 
prevent the development of tolerance to the 
drug on the part of the bacteria. 

The drug has established itself most firmly 
as an agent for the treatment of pneumonia 
due to the pneumococcus. Evans and Gais- 
ford<" report a reduction of mortality in 
adults from 27 per cent to 8 per cent when 
the drug was used; Agranat and others'-' 
from 10 per cent to 3.7 per cent. Graham*^' 
and his associates had 23 per cent mortality 
in a control series, 12 per cent in a serum 
treated group, and 6 per cent in ca.ses treated 
with sulfapyridine. Anderson and Dowdes- 
well<^' report a 75 per cent reduction of 

1. Evans, G. M. and Gaisford, W. F.: Treatment 
of Pneumonia with 2-(p-aminobenzenesulphon- 
amido) pyridine. Lacet 2: 1-i, July 2, 1938. 

2. Agranat, A. L., Dreosti, A. 0. and Ordman, D.: 
Treatment of Pneumonia -with 2-(p-amino ben- 
zene sulphonamido) pyridine (M & B 693). 
Lancet 1: 309, February 11, 1939 and L:icet 1: 
380, February 18, 1939. 

3. Graham, D., Warner, W. P., Dauphinee, J. A. 
and Dickson, R. C: The Treatment of Pneumo- 
coccus Pneumonia with Dagenan, M & B 693, 
Can. M.A.J. 40: 325, 1939. 

4. Anderson, T. F. and Dowdeswell, R. M. Treat- 
ment of Pneumonia with M & B 693. Lancet 
1, 262, February 4, 1939. 



mortality with a marked reduction in the 
length of the illness when the drug was ad- 
ministered. Flippin et alii<''' showed a 
mortality of 4 per cent. Favorable reports 
of its use in children have come from St. 
Louis/'*' Cincinnati,*" Baltimore,'"' and 
Durham, <" leaving little doubt as to the ef- 
ficacy of the drug in pneumococcic pneu- 
monias. 

Since October, 1938, all patients admitted 
to the Pediatric Service at Duke Hospital 
with a diagnosis of pneumonia have been 
treated with sulfapyridine. X-rays were 
taken on admission, and cultures obtained 
from the nasopharynx. The drug was then 
given in the dosage as discussed above. 
Fluids were administered freely, and the diet 
was given as tolerated. In the matter of 
duration of treatment our procedure has dif- 
fered somewhat from that used by certain 
others. Some have given massive doses for 
forty-eight hours, then stopped altogether; 
others have graduated dosage down from the 
first to the fourth day; again the drug has 
been continued for forty-eight hours after 
the temperature has reached normal. But 
there is at present no more satisfactory cri- 
terion for the withdrawal of the drug than 
the total white blood cell and the differential 
counts, which we have found of invaluable 
prognostic aid. Experience has shown us 
that if treatment is discontinued while there 
is still hematologic evidence of infection — 
i. e., elevated white cell count or toxic shift 
in the hemogram — recurrences or relapse 
may occur. This relapse usually responds 
promptly to the reinstitution of therapy. 
Clinical improvement precedes hematologic 
improvement, and the state of the process 
in the lung is more precisely reflected on the 

5. Flippin, H. F., Lockwood, J. S., Pepper, D. S. 
and Schwartze: The Treatment of Pneumococ- 
cic Pneumonia with Sulfapyridine. J. A. M. A. 
112: 529, February 11, 1939. 

6. Harnett, H. L., Hartman, A. F., Perley, A. M. 
and Ruhoff, M. B.: The Treatment of Pneumo- 
coccic Infections in Infants and Children with 
Sulfapyridine. J.A.M.A. 112: 518, February 11, 
1939. 

7. Wilson, A. T., Spreen, A. H., Cooper, M. L., 
Stevenson, F. C, Cullen, G. E., Mitchell, A. G.: 
Sulfapyridine in the Treatment of Pneumonias. 
J.A.M.A. 112: 1435, April 15 1939. 

8. Hodes, H. L., Stifler, W. C, Walker, E., Mc- 
Carty, M. and Shirley, R. G.: The Use of Sul- 
fapyridine in Primary Pneumococcic Pneumonia 
and in Pneumonococcic Pneumonia associated 
with Measles. J. Fed. 14: 417, 1939. 

9. MacColl, W. A.: Clinical Experience with Sul- 
fapyridine. J. Fed. 14: 277, 1939. 



34 



KORTII CAROLINA MEDICAL JOURNAL 



January, 1940 



laboratory sheet than on the temperature 
chart. 

In the group studied, temperatures on ad- 
mission varied from 102 to 106'F.. but be- 
gan to fall within twelve hours after treat- 
ment was begun, and in over half the cases 
reached normal values in twenty-four hours. 
The fall in temperature was accompanied by 
relief from anorexia and toxicity. This ap- 
parently represents a rapid lysis rather than 
the usual crisis of lobar pneumonia. Im- 
provement was continuous, except for an 
occasional relapse of temporary nature as 
discussed above. The blood picture and x- 
ray film corroborated the clinical impression 
of improvement. 

The results of treatment as outlined above 
have been very satisfying. Fifty-eight chil- 
dren with pneumonia proven by x-ray have 
received the drug. The differentiation be- 
tween lobar- and bronchopneumonia was 
made by x-ray and by the clinical aspects of 
the disease. It would be impossible to sepa- 
rate the two groups on the basis of reaction 
to treatment, for it was much the same in 
both. Table I gives the distribution of the 
patients by age. 



cases the temperature was normal in thirty- 
eight hours, and no complications (em- 
pyema, etc.) developed. As shown on Table 
I, only one patient with lobar pneumonia and 
four with bronchopneumonia died. All of 
these were under nine months of age; two 
had been premature infants; one expired 
probably as the result of a transfusion reac- 
tion. None of these five patients showed 
any beneficial reaction toward any form of 
treatment given. 

The concentration of the drug in the blood 
varied from 1.1 to 15.2 mg. per cent in the 
total group of subjects, with a majority be- 
tween 3 and 5 mg. per cent. This is ap- 
parently an effective level. Marshall's method 
for sulfanilamide determination was used, 
with sulfapyridine substituted in the .stand- 
ard solution. 

Five cases of pneumococcal empyema have 
also been treated with sulfapyridine. In all 
cases the fluid was sterilized by the third 
day, but in no case did the condition clear 
without drainage. One patient, a six months 
old boy, who had been ill with empyema for 
eight weeks, died after 60 hours of treat- 



Table I 







Bronchopneumonia 


Lobar 


Pneu 


monia 








Age 


Number 


Per 


Number 


Number 


Per 


Number 


Total 


Per 


Total 


Years 


Patients 


Cent 


Deaths 


Patients 


Cent 


De.itlis 


Patients 


Cent 


Deatlis 


0-1 


14 




43 


4 


7 


28 


1 


21 


36.0 


5 


1-2 


8 




23 





5 


20 





13 


22.5 





2-5 


5 




15 





n 


24 





11 


19.0 





5-11 







19 





7 


28 





13 


22.5 






Of the cases listed as bronchopneumonia, 
the predominant organism from the naso- 
pharynx was in 8 instances the Beta hemoly- 
tic streptococcus, in 8 the hemolytic strep- 
tococcus, and in 17 the two were found to- 
gether. Pneumococci w^ei'e isolated from 17 
of the 25 cases of lobar pneumonia, but not 
all of these could be typed, since some were 
cultured after sulfapyridine therapy had 
been started, and it is well known that after 
the drug has been given the capsule of the 
organism loses its ability to react to specific 
sera. Types II, IV, VIII and XI were identi- 
fied. 

The average length of illness before enter- 
ing the hospital was .3.1 days in lobar 
pneumonia and 4.4 days in bronchopneu- 
monia. The duration of treatment was 4.8 
days in both groups. In the average of all 



ment ; and in one other case of empyema the 
fluid was sterilized, but the patient continued 
to run an elevation until drainage had re- 
moved the purulent material. In empyema 
it is our impression that the drug is of value 
in early stages to prevent massive spread of 
the process, and in later stages as an adjunct 
to drainage either by thoracotomy, aspira- 
tion or rib resection. The drug is found in 
empyema fluid in approximately the .same 
concentration as in the blood at the .same 
time. 

One case of mediastinitis, three acute 
upper respiratory conditions, one case of 
peritonitis, and one persistent bacteremia 
(all of pneumococcal etiology) have re- 
sponded well to sulfapyridine. Types I, II, 
IX, X, XXI, and XXIII have been encoun- 
tered in these last two groups. 

In other types of illness the value of sul- 



i 



January, 1940 



SULFAPYRIDINE— MacCOLL 



35 



fapyridine has not been so well established. 
With this in mind an attempt has been made 
to define the limits of usefulness of the drug. 
The following paragraphs represent the in- 
formation obtained from a group of 60 
patients suffering from a variety of com- 
plaints. 

Fifteen children had upper respiratory in- 
fections with severe enough reactions to 
warrant hospitalization, five of them being- 
complicated by suppurative otitis media. 
These were all treated on the same principle.s 
as those outlined above, with good results. 
One patient died, a nine months old child 
had had diarrhea for one week and was 
moribund on admission. The others showed 
remarkably rapid improvement, all symp- 
toms subsiding within two days. About half 
of these cases were caused by the Beta hem- 
olytic streptococcus, and the remainder 
yielded hemolytic staphylococci or mixed 
organisms on culture. Those with .strepto- 
coccal infections responded a little more 
rapidly than those with other organisms. We 
have had few acute streptococcal infections, 
and very little has appeared in print in re- 
gard to the treatment of the streptococcal 
diseases.. Experimentally the drug is said to 
be as effective as sulfanilamide. Conclusions 
in this regard must await further trial. 

No information on a large group of cases 
infected with the hemolytic staphylococcus 
aureus has come to our attention, although 
several isolated reports have appeared. Bliss 
and LongC") report that sulfapyridine is 
more effective than sulfanilamide in experi- 
mental staphyloccoccal infections in mice. 
Our series is small, but certain impressions 
have been gathered which seem to be worth 
reporting. In conditions in which the sta- 
phylococci are on the skin, tonsils, or "out- 
side" the body, sufficient help can be had 
from the drug alone to overcome the infec- 
tion. When the organism invades the deeper 
tissues, the blood stream, or the central 
nervous system, the drug appears to do little 
more than hold the infection in check and, 
unless the antibody response by the patient 
is immediate, the drug proves inadequate. 
One patient with staphylococcus bacteremia 
showed only slight improvement during six 

10. Bliss, E. A. and Long, P. H.: Comparative 
Therapeutic Effect of Sulfapyridine in Experi- 
mental Staphylococcus Aureus Infections in 
Mice. p^oc. Soc. Exp. Biol, and Med. 40: 32, 
1939, 



days of sulfapyridine therapy, but was well 
two days after 20,000 units of staphylococcal 
antitoxin had been administered. Similarly 
a patient with chronic low grade pneumoni- 
tis, who persistently yielded staphylococci on 
throat culture after six weeks of sulfapyri- 
dine, cleared completely when staphylococcus 
toxoid was given also. On the other hand 
some of our cases of staphylococcal septi- 
cemia have died in spite of a combination of 
all therapeutic measures at our disposal. 
Nevertheless, in these severe infections, sul- 
fapyridine in conjunction with serotherapy 
appears to offer more hope of cure than any 
other measure we have possessed heretofore. 

Many papers have appeared in the English 
journals concerning results obtained in the 
treatment of acute gonococcal infections. 
The latest of these,"" gives a summary 
of the work which has gone before, and re- 
ports a 93 per cent cure in 97 patients with 
gonorrhea. Our experience has been neither 
so vast nor so encouraging. Three cases of 
vaginitis have responded remarkably well, 
but in a case of opthalmia a staphyloma de- 
veloped and the eye was lost. 

We have treated four cases of meningitis, 
with one death. This patient had symptoms 
of a brain abscess. The other three were 
caused by M. catarralis, meningococcus, and 
staphylococcus. All responded well, and 
within three days all symptoms of disease 
had disappeared. Seven cases of pneumococ- 
cus meningitis have been reported as having 
recovered. "-',<">. It is interesting that 
only about 40-60 per cent of the drug per- 
meates the spinal canal, suggesting that a 
heavier dosage may be indicated in meningi- 
tis. 

With regard to the toxicity of sulfapyri- 
dine, early reports were apparently over- 
optimistic. It was originally stated that 
only one-fourth the toxicity of sulfanilamide 
was to be expected, but recently numerous 
reports have shown it to have all the toxic 
effects of sulfanilamide. This is not too 
startling, inasmuch as sulfapyridine contains 
the entire sulfanilamide radical. Acute hem- 
olytic anemia, agranulocytosis, mental ef- 
fects, vomiting, cyanosis, hematuria, photo- 

11. Bowie, F. J., Andersoi., T. E., Dawson, A., and 
MacKay, J. F. Treatment of Gonorrhea by 
B & B 693. Lancet 1: 711, April 8, 1939. 

12. McAlpine, D. and Thomas, G. C.: Pneumo- 
coccic Meningitis Treated with M & B 693, 
Lancet 1: 1754, April 1, 1939. 



XORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



sensitization of the skin, and fever have all 
been recorded. The most troublesome of 
these has been vomiting, and enteric coated 
tablets and other measures are being tried 
to obviate this difficulty. Vomiting has oc- 
curred with a frequency of about 25 per cent, 
but has seldom been severe enough to inter- 
fere with therapy. Acute anemia and agra- 
nulocytosis do not progress after the drug 
is discontinued, and no fatal case has been 
recorded as yet. Several workei-s<"" have 
found crystals of the drug in the kidneys 
and ureters of animals who developed hema- 
turia during treatment. Crystals have also 
been noted in the urine of patients develop- 
ing hematuria. Thus, for general use, the 
same precautions as those used with sul- 
fanilamide mu.st be employed. 

Perhaps it should be emphasized here that 
all low white cell counts do not mean agra- 
nulocytosis. We have observed several cases 
in which the count fell to values of 2500 to 
3000. In all of these there were still 50 per 
cent or more granulocytes. The interpreta- 
tion apparently is that the marrow has been 
working overtime to meet the demands of 
the body while the infection has been pro- 
gressing, as evidenced by the appearance in 
the blood of large numbers of immature cell 
forms. When the infection has been over- 
come by the action of the drug plus the im- 
munizing response of the body, the demand 
for white cells falls, the marrow stops put- 
ting out immature forms and, as it were, 
catches up on production; for, when the 
count rises again, the mature forms are back 
to their normal propoi'tion. Thus the ex- 
planation for the low count would be the 
destruction of the immature forms in the 
cii'culating blood, and the temporary lack of 
production on the part of the marrow. 

Numerous clinicians have suggested that 
the drug has an antipyretic action similar to 
the salicylates. That this is not the case is 
suggested by the following observations ; 
(1) Sterile fever induced in rabbits failed 
to respond to administration of the drug; 

13. Antopol, \V. and Robinson, H.: Urolithia.iis' 
and Renal Pathology After Oral Administra- 
tion of 2 (Sulfanilyamino) pyridine (Sulfapy- 
ridine). Proc. Soc. Exp. Biol & Med. 40: 428, 
1939. 

Gross, P., Cooper, F. B. and Lewi.s, M,: Urin- 
ary Concretions Caused by Sulfapyridine. Ibid 
p. 448. 



(2) a case of acute rheumatic fever failed to 
show any lowering of temperature, but re- 
sponded promptly to salicylates; (3) a mic- 
rocephalic who ran an irregular high fever 
did not respond to the drug; (4) the temp- 
erature and white blood cell curves parallel 
each other so closely that one cannot escape 
the fact that the lowering of temperature is 
due to diminution of the amount of infection. 

Summary 

Observations obtained from si.x months' 
clinical experience with sulfapyridine are 
presented with such reports from the litera- 
ture as have bearing on the use of the drug 
and its effect on disease. Our dosage and 
method of treatment have been outlined. 

Sulfapyridine appears to have established 
itself not only as an effective chemothera- 
peutic agent for the management of pneumo- 
coccal infections but of bronchopneumonia 
as well, bringing about marked improvement 
within thirty-six hours despite the duration 
of the disease prior to treatment. The white 
blood cell count is the most reliable index of 
the state of the patient. 

Severe upper respiratory infections have 
responded well to sulfapyridine therapy. 

Staphylococcal infections in general are 
controlled by sulfapyridine, and streptococ- 
cal diseases are probably susceptible to its 
effect. The former will respond better to a 
combination of chemo- and serotherapy than 
to either alone. 

Infections by Neisserian organisms re- 
spond well to sulfapyridine. 

All the major toxic effects of sulfanila- 
mide have already been recorded in sulfapy- 
ridine therapy. 

It is our belief that the drug does not have 
an antipyretic effect. 



The Future of Medicine. — We need have no fears 
that the development of medicine is at an end. Even 
though the world be ti-oubled, we may confidently 
look for peace and satisfaction in the field of medi- 
cine, a field which is only at the beginning of pos- 
sibilities of service and benefit to mankind. That 
medicine will continue as a profession in the hands 
of men possessed of individual initiative and of pro- 
fessional ideals, we likewise need have no doubt. — 
Winfred Overholser: The Broadening Horizons of 
Medicine, Science, 90:2338 (Oct. 20) 1939. 



January, 1940 



DIPHTHERIA CONTROL— KNOX 



87 



SOME PROBLEMS OF DIPHTHERIA 
CONTROL* 

Dr. J. C. Knox, Director, 

Division of Epidemiology , North Carolina 
State Board of Health. 

In many sections of the United States 
diphtheria has decreased to the point that it 
is no longer a public health or medical prob- 
lem of significance. This is not so in North 
Carolina ; for during the past five years there 
have been 10,679 cases and 909 deaths from 
this disease reported in our state. The case 
fatality rate has not materially changed, 
even though the specific death rate has 
shown a decrease. The questions naturally 
arise, "Why is this true? Why does North 
Carolina have nearly 7 per cent of all the 
diphtheria reported in the United States? 
Are there factors involved that we have over- 
looked?" A study of our problem from a 
number of different angles may disclose 
some of the reasons why our record is so 
unsatisfactory. 

There seems to be no specific peculiarity 
of the disease itself in this .section of the 
United States which could account for the 
large number of cases. According to avail- 
able records case fatality remains about as 
it has in this state and is not out of line with 
that of other sections of the country. ''Laryn- 
geal diphtheria is still the form of this di- 
sease which causes the greatest mortality. 
As yet there have not been definitely identi- 
fied in North Carolina cases of diphtheria 
gravis such as have been reported from time 
to time in European countries. This type 
apparently does not respond to the adminis- 
tration of diphtheria antitoxin as does the 
ordinary case of diphtheria. It is quite like- 
ly that this strain of organism produces 
toxin more rapidly than other strains, which 
of course would indicate the need for im- 
mediate administration of adequate doses of 
a potent antidiphtheritic serum. 

The age incidence of diphtheria in North 
Carolina runs about as it has for years and 
as it is found in other Southern states. 
Dauer,<i> in making a study of diphtheria in 
the South, concluded that the ages most 



*Read before the Pediatrics Section of the Medical Society of 
the State of North Carolina, Bermuda Cruise, May 10, 1939. 



(1) Dauer, C. C: Morbidity and Mortality from 
Dipththeria in the South, Am. J. Hyg. 23:3 
(May) 1936. 



affected by diphtheria are those of the pre- 
school child. This varies somewhat from 
findings in some of the Northern states, 
where older age groups were chiefly affected. 
We in North Carolina have known for years 
that the majority of our cases occur in the 
ages from one to five years; about 55 per 
cent of all our cases are in this group. 
Naturally we would expect to find the high- 
est mortality in these .same ages ; 80 per cent 
of deaths occur here. There seems to be no 
significant variation in rural and urban chil- 
dren. Possibly a higher percentage of deaths 
may be found in rural than in urban chil- 
dren, but this very likely would be due to 
the lack of prompt medical service when the 
child becomes ill. There is still an urgent 
need for prompt and early treatment of all 
diphtheria cases if we are to get the best 
results from the administration of diphtheria 
antitoxin. 

Here let me urge not only the early ad- 
ministration of diphtheria antitoxin but also 
adequate single doses of a potent product. 
This may be given by either of three routes: 
subcutaneously. intramu.scularly or intrave- 
nously. Care .should be exerci.sed in order 
that severe serum reactions may be avoided. 
Sensitivity tests should precede any admin- 
istration of serum, whether antidiphtheritic 
or other. 
''The only method which will give maximum 
results in our effort to control diphtheria is 
proper immunization of the susceptible child 
or adult. This tells nothing new. The va- 
rious health departments have been trying 
to immunize susceptible children for years. 
In addition, they have tried to educate the 
parents to the necessity for their coopera- 
tion with the family physician. This ques- 
tion arises to plague us : "Have we been im- 
munizing the right children?" It seems 
reasonable to assume that the public health 
ofl^cer has done what anyone else in his posi- 
tion would do — that is, immunize those who 
are easy to assemble and who are most easily 
reached. It naturally follows that children 
of school ages would comprise this group; 
and these school children are past the most 
susceptible ages, so far as diphtheria is con- 
cerned. This is not a condemnation of the 
health officer's efforts, for quite likely diph- 
theria incidence would have been consider- 
ably higher had he not carried his immuni- 
zation program into the schools. Perhaps 



38 



NORTH CAROUNA MEDICAL JOL'RXAL 



January, 1940 



our recorded decrease in diphtheria in North 
Carolina in recent years, as compared vdth 
the high incidence of earlier years, is due to 
the immunization of these same school chil- 
dren. If this is true, then \ve must redouble 
our efforts to protect the pre-school child as 
well as continue our control program in the 
public schools. 

If the program of diphtheria control is to 
be most effective it is necessary to immunize 
the pre-school child. Furthermore, we should 
not consider the term "pre-school child" as 
applicable only to the child who is in his 
fifth year of life or who is to begin school 
the following year. The ideal procedure is 
immunization of each child during his first 
year of life. The protection afforded by in- 
oculation with toxoid should be confirmed by 
the presence of a negative Schick test made 
three to six months later. 

The private practitioner is in better posi- 
tion to perform this service for his patients 
than is anyone else. As was clearly demon- 
strated last year before this Society in a 
paper by Doctor Bugg<-* of Raleigh, the 
family physician is the most important fac- 
tor in making diphtheria as rare in North 
Carolina as is smallpox. Should not the 
family physician be privileged to insist upon 
parents bringing their babies back to his 
office for protection against this most deva.<- 
tating disease? The time generally agreed 
upon as the best for immunization is during 
the second half of the first year of life. It 
matters little whether the age selected is at 
six months or nine months. We must re- 
member that diphtheria does occur under 
one year of age. Our records for 1938 show 
that 56 of the 2.442 reported diptheria cases 
occurred in children under one year of age. 
The important thing is that immunization be 
done. The family doctor has a responsibility 
to fulfill in his capacity as medical adviser 
to the family and should feel as free to insist 
upon immunization against diphtheria as he 
would to insist upon protection by vaccine 
of those in a family who had been exposed 
to typhoid fever. 

The last General Assembly in North Caro- 
lina enacted a law requiring immunization 
of all babies between the ages of six and 
twelve months. This measure is a wise pub- 

(2) Bugg, C. R.: Some Aspects of the Diphtheria 
Problem, Transactions of the Medical Society of 
the State of North Carolina, 193S, p. 130. 



lie health procedure, and if scrupulously fol- 
lowed, will eliminate diphtheria, or at least 
make it a rare disease in our state. This 
should not be such a difficult task, for there 
would be about seventy thousand babies to 
be immunized each year. Within five years 
diphtheria should reach a very low incidence 
if these babies are protected within the year 
of their birth. 

The choice of an immunizing agent has 
been somewhat of a puzzle to many practic- 
ing physicians. Considerable doubt has been 
cast upon the effectiveness of alum precipi- 
tated toxoid in providing lasting protection 
against diphtheria. A fairly large number 
of children have had the disease following 
its administration. In 1937 we sent ques- 
tionnaires to even,- physician in the state 
who reported a case of diphtheria to the 
State Board of Health. This was done in an 
effort to determine the number of children 
who had previously received one of the im- 
munizing agents. In this connection, I wish 
to thank the practicing physicians of North 
Carohna for their cooperation in this study. 
Because of their assistance a much larger 
percentage of the questionnaires were re- 
turned to us with this information than are 
usually obtained in such a study. A statisti- 
cal summary of this information for the year 
1937, the period of the study, is presented at 
this time. 

A total of 2,056 cases were reported during 
1937. A questionnaire for each case was 
sent to the reporting physician. A total of 
1,516 questionnaires were returned, or ap- 
proximately 74 per cent. Of this number 
237 cases, or 16 per cent, had been previous- 
ly immunized. Of these 237 cases twenty- 
five had had Schick tests made. Of these 
twentj--five who were Schick-tested six pa- 
tients had positive tests, seventeen negative 
tests and tvvo unknown. Of those with nega- 
tive tests six had received toxin antitoxin, 
two had received toxoid, eight had had alum 
precipitated toxoid and one was unknown. 
We are not able to give the lapse of time be- 
tween immunization of the child and the time 
when the disease developed. There is a 
chance, however, that some of those receiv- 
ing an immunization agent developed the 
disease before immunitj^ had sufficient time 
to be established. 



January, 1940 

"In a recent report by Volk and Bunney'-" 
different immunization procedures were 
evaluated. Their findings indicate that one 
dose of alum precipitated toxoid is better 
than two doses of fluid toxoid, giving pro- 
tection to a greater number and maintaining 
a higher level of antibody content of the 
blood for a longer time. At the end of two 
years 77.6 per cent of children had an anti- 
body or antitoxin level that gave protection. 
At the end of the first year this was 87.5 per 
cent as compared with 60.4 per cent for two 
doses of fluid toxoid. From this study, which 
made use of controls, it seems wise to con- 
tinue the use of alum precipitated toxoid. 
They showed further that after two doses of 
alum precipitated toxoid the response after 
four months was 100 per cent. At the time 
of the report a year had not elapsed; so 
figures for this group are not available. 

McGinness<*> and Gill'"'>, who made some 
of the original investigations in this country 
on the immunizing properties of the alum 
precipitated toxoid, have unpublished data 
which indicate that permanent immunity is 
found in a larger percentage of those receiv- 
ing this agent than in those receiving other 
such agents. Furthermore, the investigators 
who originally threw doubt upon the anti- 
genic properties of alum precipitated toxoid 
have admitted that their original findings 
cannot be consistently confirmed. 

Conclusions 

1. That diphtheria can be controlled and 
all but eliminated if our present knowledge 
is applied to the proper age groups. 

2. That the family physician should be of 
the greatest aid to public health officials in 
bringing about the control of this disease. 

3. That alum precipitated toxoid is the 
antigenic agent of choice, and that two doses 
administered at three-week intervals is the 
method of choice. 



(3) Volk, V. K. and Bunney, W. E.: Diphtheria 
Immunization with Fluid Toxoid and Alum 
Precipitated Toxoid, Am. J. Pub. Health 29:3 
(March) 1939. 

(4) McGinness, Virginia State Health Department 
(by personal communication with author). 

(5) Gill, Alabama State Health Department (by 
personal communication with author). 



THE ELECTROCARDIOGRAM— McNeill 



39 



THE ELECTROCARDIOGRAM AS AN 
AID IN CARDIAC DIAGNOSIS* 

James H. McNeill, M.D. 

North Wilkesboro 

Within recent years, electrocardiographs 
have been so simplified that they are coming 
into general use. It seems timely, there- 
fore, to stress the fact that the cardiogram 
is only an aid in cardiac diagnosis. The 
tracings alone should never be used as the 
sole means of cardiac examination. With 
the addition of each new instrument of pre- 
cision to our armamentarium, we are prone 
to put too much reliance on the technical 
findings and not to rely enough on our his- 
tories and physical examinations. 

Dr. Paul D. White starts the section on 
electrocardiography in his book<" with the 
following paragraph : 

"The electrocardiograph does not take the 
place of such other methods of examination 
as history taking, percussion, auscultation 
and roentgenology but it does obviate in 
large part the need of taking mechanical 
graphic records of arterial and venous pulses 
and of the apex impulse. Finally, it must 
be realized that the electrocardiogram may 
be perfectly normal, even in the presence of 
serious heart disease. This method of study 
should therefore be viewed modestly as help- 
ful and supplementary, but not accorded too 
great importance." 

The electrocardiogram will give us valu- 
able information on: (1) the rate and 
rhythm (2) the size of the chambers of the 
heart (3) the condition of the conorary 
arteries, and (4) the condition of the heart 
muscle. 

To appreciate the abnormalities to be 
shown, we must first know the normal trac- 
ing. The configurations of the tracing are 
produced by photographing the motions of a 
galvanometer string activated by the heart's 
current. Motions of the galvanometer string 
produce different waves, arbitrarily de- 
signated by letters. The P wave is that one 
produced by the contraction of the auricles, 
the QRS complex is produced by the spread 
of electrical current over the ventricles, and 
the T waves are pi-oduced by ventricular 
contraction. Voltage of the different waves 
(shown by horizontal lines 1 mm. apart), 



*Read before the Section on the Practice of Medicine, Medical 
Society of the State of North Carolina, Bermuda Cruis-e, 
.May 13, 1330. 



40 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 




Figure 1. Normal Electrocardiogram. 
Figure 3, Auricular Fibrillation. 

their direction, shape and time relationships 
(measured by the vertical lines indicating 
0.04 second intervals) will vary with differ- 
ent heart diseases. The base line will vary 
in shape with certain conditions. It is upon 
these variations in shape, amplitude and 
time relation.ships that we interpret our 
tracings. 

Each heart contraction is shown by the 
combination of waves. P. QRS.and T. (fig. 1). 
The auricular wave (P) initiates the comple.x 
with an upward swing of one to two mm 
It lasts not more than 0.1 second. Within 
0.2 seconds of the beginning of P, the QRS 
group is shown. This group may begin 
with a small downward deflection (Q) fol- 
lowed by a large upward excursion (R) of 
7 to 17 mm. and then another small down- 
ward deflection (S). It must not take more 
than 0.1 second for this electrical spread to 
take place. This is followed by the ventri- 



Figure 2, a) Sino- Auricular Tachycardia, b) Sinus 

Bradycardia, c) Sinus .\r\thmia. 
Figure 4, a) First Degree Auriculo-Ventricnlar 
Block, b) 2:1 -W Block, c) Complete Heart Block. 

cular wave, T. The T wave is a peaked or 
rounded upward deflection of from 1.5 to 
5 mm. and lasting about 0.2 second. This 
wave is followed by the straight base-line of 
diastole in which no electrical change takes 
place. 

Disturbance In Rhythm 

The impulse stimulating the contraction 
of the heart originates at the si no-auricular 
node and such rhythm is known as sinus 
rh\-thm (fig. 1). The impulses to beat 
may originate too rapidly, giving sinus 
tachycardia, (fig. 2A) or too slowly, giving 
sinus bradycardia (fig. 2B). The origin of 
the impulse may be affected by the respira- 
tory phase, gi\ing sinus arh\-thmia charac- 
terized by slowing of heart rate on expira- 
tion (fig. 2C). These are the simplest and 
most frequent arj-thmias and usually do not 
signify any cardiac disease. The sinus tachy- 



January, 1940 



THE ELECTROCARDIOGRAM— McNeill 



41 



cardia shown occurred in an anemic patient, 
while the bradycardia was in a patient hav- 
ing a brain tumor with increased intracra- 
nial pressure. Auricular tachycardia may be 
due to disturbance in the nerve mechanism 
of the heart, to hyperthyroidism, infection, 
anemias and many extracardiac diseases. 
Sinus bradycardia, on the other hand, may 
be due to excessive vagus activity, to in- 
creased intracranial pressure and may be 
present normally in men of the athletic type. 

Probably the next most frequent arythmia 
is auricular fibrillation (fig. 3). In this 
state the sino-auricular node does not origi- 
nate the impulse to beat, but the auricular 
wall is in circus-like movement sending im- 
pulses to the ventricles at the rate of 350 to 
500 per minute. Naturally, the ventricles 
are unable to respond to this i-apid rate and 
respond irregularly with systoles. These 
tracings show an absolute lack of rhythm in 
ventricular activity and a wavy, irregular 
base line representing the fibrillation of the 
auricles. Practically always, this arythmia 
means a diseased auricular myocardium, 
be due to poor coronary circulation, to hy- 
perthyroidism, to toxicity as in pneumonia 
or to arteriosclerosis. 

Auricular flutter sometimes precedes fib- 
rillation. In this condition, the auricles are 
beating rapidly and regularly as shown by 
flutter waves in the base line of the tracing. 
The ventricles are unable to respond at so 
rapid a rate, so that there is an auricolo- 
ventricular block in the ratio of 2:1, or 4:1. 
Flutter may be a toxic response but is usual- 
ly due to a diseased myocardium. 

Toxic processes, inflammatory reactions 
and fibrosis of heart muscle affect the con- 
ducting mechanism, producing varying de- 
grees of block (fig. 4). The first degree is 
shown by a delay of more than 0.2 seconds 
in the conduction of the imjjulses from the 
sino-auricular node to the ventricle (4-A). 
Such a blocking is often present in many 
infectious processes, particularly in active 
rheumatic fever. Arteriosclerosis is also a 
frequent producer of varying degrees of 
block. In a higher degree of AV block, the 
ventricle fails to respond to a half or a third 
of the auricular impulses. Thus the tracing 
will show P waves at regular intervals and 
QRS complexes following every second or 
third P wave. The block shown here (4-B) 
was produced by toxic action of digitalis. 
In severe toxic states and in marked myo- 



cardial disease, there may be a complete dis- 
sociation of auricle and ventricle, the auricle 
beating at one rate, the ventricle at another, 
and the ventricular systoles showing their 
ventricular origins by slow rate and pro- 
longed QRS phases. This figure (4-C) shows 
complete block due to a diphtheritic myo- 
carditis. 

The conducting bundle of His may be so 
affected with scarring, fibrosis, or inflamma- 
tory processes that the spread of the im- 
pulses over the ventricles is delayed longer 
than the normal 0.1 second (fig. 5). With- 
out characteristic axis deviation, this is 
known as intraventricular block. If the left 
bundle branch is more involved, the above 
description holds true and is accompanied by 
an inverted T/1 with left axis deviation. In 
right bundle branch block, T/1 is upright, 
T/3 is inverted and there is a right axis 
deviation. Any form of intraventricular 
block must be regarded very seriously al- 
though it is possible for patients with this 
lesion to live comfortably for many years. 
It is usually due to coronary arteriosclerosis 
or to syphilis. 

Extrasystoles, either auricular or ventri- 
cular, frequently produce an arythmia of 
which patients complain (fig. 6B). When 
the extrasystole is auricular in origin, the P 
wave is present, but it may differ from other 
P waves shown in the strip. After it, comes 
a ventricular QRS complex like all the others. 
The compensatory pause after an auricular 
extrasystole is usually a little shorter than 
after a ventricular extrasystole. Aberrant 
beats arising in the ventricular muscle show 
a different QRS and T (fig. 6A), being usual- 
ly larger and of longer duration. In them- 
selves, these abnormal beats do not neces- 
sarily mean a diseased heart muscle, but 
they do imply the presence of an irritable 
focus in either the auricular or ventricular 
myocardium. They are frequently detected 
in the presence of chronic intoxications as 
from excessive use of tea, coffee, tobacco, 
alcohol, and from chronic focal infection. 
They also occur frequently in the presence 
of myocardial disease. 

Changes in Size of the Chambers 
of the Heart. 

As we have seen before in the normal 
heart, (in which the ventricles and auricles 
are relatively proportionate), the main 



N'ORTH CAROLINA MEDICAL JOURNAL 



4^6^ 











^7 



,H.T 



4n.'A*<'>WA^'A^/— •A^''A-''^«».V*k.'^^V. 



I ■ 



j^'^A 



III 





liKUre .">. Intraventricular Block. 

Kicure 7, Large P Waves. 
Figure 9. KiKht .\xis Deviation. 

swings of the QRS groups are directed up- 
ward. With h.vpertrophy of one ventricle 
there will be a rotation of the heart's electri- 
cal axis toward the enlarged ventricle. This 
rotation produces a deviation of the axis of 
the QRS groups, so that in right axis devia- 
tion (tig. 7). the main swing of the QRS 
group is downward in lead one — i.e., the volt- 
age of the S wave in lead one exceeds that 






Figure 6. Extrasystoles a) Ventricular b) .\uricular. 

Figure 8, Left .\xis Deviation. 

Figure 10, Early Conorary Occlu.sion. 

of R 1. In right axis deviation lead two 
will be approximately an average of leads 
one and three. Lead three will have its main 
swing in an upward direction. This find- 
ing is quite constant in both mitral stenosis 
of rheumatic heart di.sea.se and in obstruc- 
tion to the pulmonary circulation, both of 
which conditions jn-oduce right ventricular 
hypertroi)hy. 



January, lt)40 



THE ELECTROCARDIOGRAM— McNeill 



43 



Left axis deviation is shown (fig. 8), by 
an upward swing of QRS in lead one with 
a negative deflection of that group in lead 
three — i.e., S/3 has a greater voltage than 
R/3. This finding is frequent in left ven- 
tricular hypertrophy due to hypertension, 
mitral insufficiency or aortic valve disease. 

Hypertrophy of the auricles does not pro- 
duce any axis deviation but shows itself in 
abnormalities of the P waves (fig. 9). These 
waves will be of abnormal height, (over 
2 mm.), of longer duration, (more than 0.1 
second) and will probably be notched. Such 
waves are frequently seen i7i mitral stenosis 
and in obstruction of the pulmonary circula- 
tion. 

Axis deviation may, in some cases, not in- 
dicate hypertrophy. The build of the patient 
and the patient's position while the tracing 
is being made may influence the axis. Thus, 
a very thin subject may have a right axis 
deviation with no heart disease, while a left 
axis deviation may normally be present in 
obese subjects. 

Hypertrophy of itself does not imply a 
weakened myocardium, but merely an effort 
on the part of the heart to overcome a me- 
chanical obstruction. So long as we have 
only axis deviation present in the ti'acing 
we may say that the heart muscle is sound. 

Occasionally, we may see a heart greatly 
enlarged and not showing any axis devia- 
tion. This is likely to occur when both sides 
of the heart are equally enlarged as in ad- 
vanced arteriosclerosis and hypertension. 
Left axis deviation is usually present how- 
ever. 

Diseases of the Coronary Arteries 

The electrocardiograph's greatest use lies 
in the detection of coronary artery occl- 
usion and coronary artery disease. Here 
we have definite findings in approximately 
80 per cent of patients with this condition. 

Within a few hours to a day or two after 
an acute occlusion, definite changes take 
place in the ST segment (fig. 10). Instead 
of passing from S to T level with the base 
line, this segment will pass directly from 
about the mid-portion of R or S to T, so 
that this segment is elevated above or de- 
pressed below the base line. Usually when 
the ST segment is above the base line in 
lead one, it will be below in lead three, and 
vice versa. These changes usually are ac- 
companied by a deep Q wave either in lead 



one or three. Anterior infarction is shown 
by an elevated take-off of ST, with a de- 
pressed take-off of ST/ 3 accompanied by a 
deep Q/1. Posterior infarction is shown by 
the opposite — i.e., a depressed take-off of 
ST/1, elevated take-off of ST/3 and a deep 
Q/3. These abnormal take-offs persist for 
several days. 

As healing occurs, the ST segment tends 
to approach a level with the base line (fig. 
11). This leads to the production of the 
"Coronary T wave". This is characterized 
by an upward convexity in the ST segment 
leading to an inverted T wave. In anterior 
infarction this abnormal T wave is found 
in leads and and two. T/3 is directed up- 
ward. Posterior infarction produces an op- 
posite eft'ect — i.e., the ST convexity and the 
inverted T wave is found in lead three and 
T/1 is upright. 

As years or months go by, these coronary 
T waves may be replaced by normal ones, 
but frequently they persist. 

Coronary artery disease may be implied 
by signs of myocardial disease, of which, 
more later. A deep Q/3 (fig. 12) is fre- 
quently found in patients having coronary 
artery sclerosis and in those having angina 
pectoris. To be considered deep, Q/3 must be 
25 per cent or more of the greatest excursion 
of QRS in any of the three standard leads. 
A deep Q/1 would probably have the same 
significance. 

Unfortunately, the electrocardiogram 
shows nothing typical in angina pectoris. 
During an attack a tracing like that de- 
scribed for acute occlusion may be found, 
and a normal tracing may be obtained an 
hour or so after the attack. A deep Q/3 must 
be considered strongly suggestive of angina. 

Changes Due to a Diseased Myocaraium 

Under previous headings we have men- 
tioned several of these electrocardiographic 
signs of a diseased muscle — namely, auricu- 
lar fibrillation, AV block, intraventricular 
block, bundle branch block, coronary T waves 
and deep Q waves. 

Further evidence of myocardial disease is 
obtained from the appearance and voltage 
of the QRS groups and by the amplitude and 
direction of the T wave. 

Notching or slurring of QRS (fig. 13) 
in a complex of low voltage may not be 
significant, but when it is present in a com- 
plex of average amplitude, particularly if it 
is accompanied by any other abnormality, 



44 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



we may safely say that the myocardium is 
diseased. This finding is usually permanent 
and occurs in rather diffuse myocardial 
fibrosis. 

Recall that the normal voltage of the QRS 
complex varies between 0.6 and 1.7 mv. The 
amplitude of the QRS complex is determined 
to some extent by the functional state of 
the heart muscle, but it is generally believed 



that voltage of over 1.7 mv. is an indication 
of hypertrophy when no notching is present 
in the swing. Voltages below O.Smv. (fig. 14) 
always indicate a diseased heart muscle. 
To be significant, the low voltage mu.st be 
present in all three leads — i.e., if the QRS 
complexes are low in one lead only and the 
voltage is adequate in the others, no signifi- 
cance is attached to the finding. Hypothy- 
roidism frequently produces low voltage of 



■^ 






wv.«~-"-»-''' ^"'"■" — ■'^ — ^*-'-— ~^-"-'-'-^ a -r 


a'V « 


-'v.->X».~^ 


'v„^._t-'«^ '>^^^'y-X'v-<-Ai'Sr^>^-'<^ f^ 






. e T . 


■v'^-^ 


.■■■■ T ' R 


■#/i'^ 


' ■ ■ 


^^ < v**^ x/^-v^ •«>•»«•■'- -.'«.- II 


■ "V ^'^ 




•..•"'V"^ 


Hi 




■^ J(^ 


- w-.^_.- T _^^^ n 




ii 


-4^ 


Ill 

> 





I'iKiir<" 11, Coronary T Waves. 

Figure 13. .NoUhinK and .Slurring of QRS. 

Figure 15, Low VoltaRe of T Waves. 



ri(;ure 12. Deep Q/3. 

Figure 14. Low Voltage of ((KS. 

Figure 16, Inverted T/2. 



January, 1940 



THE ELECTROCARDIOGRAM— McNeill 



45 



QRS. Generalized myocardial fibrosis will 
frequently cause the same thing. 

The amplitude of the T wave is also partly 
dependent upon the functional state of the 
heart muscle, normal varying from 0.15 to 
0.5 mv. (fig. 15). Here too, the finding of 
a low T wave, in one lead only, is insignifi- 
cant. If however the voltage is below 0.15 
mv. in all three leads we must say that the 
myocardium is impaii'ed. A still more sig- 
nificant finding is the inversion of T in lead 
one or two (fig. 16). This always means a 
diseased myocardium unless it occurs in an 
extrasystole. 

Conclusion 

An effort has been made to review some 
of the commoner electrocardiographic ab- 
normalities with the purpose of showing 
what we may learn from an electrocardio- 
gram. We may say that its greatest value 
lies in: 

(1) detecting coronary occlusion and 
coronary artery disease, (2) determining the 
rhythm, and (3) estimating the condition of 
the heart muscle. 

The making of a tracing gives little more 
information than the stethoscope in the study 
of valve lesions. In studying the condition 
of the heart muscle we are frequently able 
to evaluate more accurately an operative 
risk. The electrocardiogram is a great aid 
in cardiac diagnosis, but no diagnosis should 
be made on it alone. 

Discttssion 

DR. VERNE S. CAVINESS (Raleigh): Mr. Cliaii- 
man and Gentlemen: I have enjoyed Dr. McNeill's 
paper very much. He has given us a concise cover- 
ing of the subject, and it is a subject which is be- 
coming of more widely recognized importance. 

I think that the chief and perhaps the most valu- 
able point that he has made is the necessity for co- 
ordination in this branch of medicine, as in all 
others, between the laboratory and the clinical find- 
ings. I don't think we are justified at any time in 
taking the clinical stethoscopic and exercise tests, 
and the history of the patient, without adding the 
caridogram if the patient has a very definite cardiac 
disease or symptoms. 

There are a number of factors that have to be 
considered. Sometimes, I think the type of machine 
receives too much importance. A good workman 
never blames his tools. But I do think that there 
are variations in machines, and that these varia- 
tions in the type of tracing made must always be 
considered in interpreting' and evaluating the results. 

The technique, in making the tracings is very im 
portant and requires' a great deal of attention. A 
tracing can be made which is utterlv valueless, or 
one can be made which is perfectly good. One 
thing that must be remembered always is the stana- 
ardization of the string, if you use a machine that 



has a string. The interpretation and evaluation of 
the results of tracings, however, are far more im- 
portant than the actual technique of making the 
tracings. 

Dr. McNeill stated the chief value of the cardio- 
gram is the evaluation of the functioning of the 
heart muscle. There is no other way of making 
such an accurate evaluation of the qualities in the 
heart muscle. If this is adhered to, and if we 
make a careful cardiographic study of all suspected 
cardiac cases, I think it would be of great help to 
the neuro-psyehiatrists. All of us have seen many 
patients who were told they had heart trouble and 
were made permanent neurotics by misinformation. 
Frequently, these patients have no heart trouble, 
and it is difficult later to convince them of the fact 
that they have been misinformed in the beginning. 

Checking treatment is a point at which we can 
make good use of the cardiograph. When a patient 
is first seen, we frequently find that he has been 
taking large amounts of digitalis and shows effects 
of digitalis poisoning which, at times, even the best 
of clinicians can confuse with definite heart disease 
in the cardiograms, unless they make a very care- 
ful interpretation. I am sure all of us remember 
life insurance scandals of that sort that occurred 
relatively recently. 

To those of you not familiar with the making of 
the cardiograms, lead one is the difference in electri- 
cal potential between the right ann and the left 
arm. Lead two is the difference in electrical po- 
tential between the right arm and the left leg. 
Lead three is the difference between the left leg 
and the left arm. The fourth lead, or multiples of 
that as desired, is the difference between the chest 
and one arm or one leg. 

From this I think you can see it is relatively 
easy to get a change in electrical potential. In 
drawing up instructions for the making of cardio- 
grams, you cannot presuppose abnormal positions 
of the heart or variations in the position of the body. 
A tranverse heart will give quite a different tracing 
from a vertical heart. I mention that to show the 
importance of giving careful consideration to all 
your clinical findings, as well as to interpretations 
of the cardiogram itself. 

Cardiograms have great value in other ways. 
When a patient passes the age of forty, begins 
getting into the age of arteriosclerosis and the other 
chronic degenerative diseases, and comes up for an 
elective surgical operation, the mortality rate can 
be greatly reduced by a careful study of the circu- 
latory system. Various hospitals have reduced their 
operative mortality practically to zero in various 
types of operations by refusing to do elective opera- 
tions on patients who have definite indication of 
coronary sclerosis, or other heart disease. 

DR. WILLIAM B. DEWAR (Raleigh): Pos- 
sibly my greatest pleasure with cardiographs has 
been helping peonle who do not have organic 
heart disease. The patient who may have the 
syndromes, after a complete study of that case, in- 
cluding history, laboratory findings, with careful 
physical examination can often be rehabilitated and 
.■<cnt back to hard work. 

DR. McNEILL: One of the points made by Dr. De- 
war was the need for reassurance. So often wo sec 
patients under emotional stress, with dyspnea on 
effort, who have been told that they have a bad 
heart. They suffer from that diagnosis for nonths 
on end, sometimes years, and it is awfully hard to 
convince them that they don't have honest-to-good- 
ness heart disease. I believe a cardiogram is our 
best means of doing that. 



46 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



North Carolina Medical Journal 

Ownied and Published by 

The Medical Society of the State of North Carolina, 
under the direction of its Editorial Board. 



EDITORIAL BOARD 
Paul P. McCain, Sanatorium, Chairman. 
W. Reece Berryhill, Chapel Hill. 
Coy C. Carpenter, Wake Forest. 
Frederic M. Hanes, Durham. 
Paul H. Ringer,, Asheville. 
Hubert A. Royster, Raleigh. 
Wingate M. Johnson, Winston-Salem, Editor. 
T. W. M. Long, Roanoke Rapids, Business Manager. 



Address manuscripts and communications to the 

NORTH CAROLINA MEDICAL JOURNAL, 

428 Stratford Road, Winston-Salem. 



January, 1940 



C^AitctiaiA 



BY WAY OF INTRODUCTION 

With this issue the NORTH Carolina Medi- 
cal Journal becomes the official organ of 
the Medical Society of the State of North 
Carolina. It will go to every member of the 
Society, the subscription being included in 
the regular dues. In this its first number 
we, the members of the editorial board, wish 
to outline the policy of the magazine so far 
as possible — bearing in mind that it is a 
newly born infant and that its features may 
change greatly as it reaches adolescence and 
maturity. 

The mission of the NORTH Carolina 
Medical Journal is to serve as a medium 
for North Carolina doctors to use in ex- 
changing ideas ; as a purveyor of worth- 
while medical information, whether from 
our own members or from guest speakers 
and writers ; as a means of contact between 
the president, the secretary, and other of- 
ficers and members of the society; as a per- 
manent record of research by society mem- 
bers; and as a news letter about the inter- 
esting doings of North Carolina doctors. 
Irvin Cobb's famous criticism of North Car- 
olina as needing a press agent applies with 
peculiar force to its medical profession. 
From first hand acquaintance we know that 
the doctors of this state will compare favor- 



ably as a profession with those of any state 
in the union ; but most of them have been 
too modest about expressing themselves. It 
is our hope that this magazine will stimulate 
a goodly number of North Carolina doctors 
to let their light .shine more brightly before 
men. 

For its material, the journal must depend 
upon a number of sources. All papers read 
before the State Society are, of course, its 
property ; but these will not be nearly enough. 
We hope to get some valuable contributions 
from guest speakers who come to our state. 
We also expect to use the best of the papers 
read at district and county meetings. We 
shall depend upon our medical schools and 
our hospitals for reports of worth-while 
clinics, clinico-pathological conferences, and 
research work. Last, but by no means least, 
we shall look to the individual doctors 
throughout the state for instructive ea.se re- 
ports and interesting news notes. 

While, for many reasons, it will be im- 
practical and impossible to print all material 
submitted, every contributor may be quite 
sure that his offering will be given a sympa- 
thetic reading by at least two men. If they 
disagree as to its merits, a third will cast 
the deciding vote. In order to do justice to 
papers submitted to the journal, every mem- 
ber of the editorial board has promised to 
help. In addition, the board has appointed 
a number of unofficial associate editors to 
represent every special branch of medicine 
as well as general practice. The names of 
these men will not appear on the masthead, 
but they will render a real service, neverthe- 
less. 

Every doctor in active practice should 
have from time to time interesting and in- 
structive ca.ses to report; bits of practical 
technique to pass on to others; observations 
worth organizing into papers for the state, 
district, or county society, to be submitted 
as a matter of cour.se to this journal. We 
want every member of the Medical Society 
of the State of North Carolina, veteran or 
fledgling, college professor or intern, to feel 
that the North Carolina Medical Journal 
belongs to him. It is the organ of the whole 
Society, and its success — let us not suggest 
any other outcome — depends upon the whole- 
hearted co-operation of the entire member- 
ship. 



January, 1940 



EDITORIALS 



if 



THE NORTH CAROLINA MEDICAL 

JOURNAL AND THE AMERICAN 

MEDICAL ASSOCIATION. 

One ambition of its editorial board is that 
the North Carolina Medical Journal may 
serve to strengthen the ties between our 
State Society and its parent, the American 
Medical Association. As a first step toward 
this aim, we are happy to present in this 
first issue greetings from the four most 
prominent oflicials of the American Medical 
Association : Dr. Rock Sleyster, President ; 
Dr. Nathan B. Van Etten,' Pre.sident-Elect ; 
Dr. Morris Fishbein, Editor of its Journal : 
and Dr. Olin West, Secretary and General 
Manager. To each of these we wish to ex- 
press our sincere thanks for their words of 
counsel and cheer ; and we pledge them, as 
heads of the A.M. A. family. North Carolina's 
unwavering loyalty. 

GREETINGS 

North Carolina Medical Journal 
The American Medical As.sociation has 
always regarded with pride and satisfaction 
the growth and progress of the constituent 
society of North Carolina. Under difiiculties 
not experienced by all of its children, the 
Medical Society of North Carolina has de- 
veloped in quality of membership, in edu- 
cational facilities, and in constructive pro- 
grams well carried out, to an envied position 
among the leading societies of this country. 
Now, the A.M. A. welcomes to the oflicial 
family of Journals one of its progeny — a 
new-born, christened "North Carolina Medi- 
cal Journal". This medium will afford op- 
portunity to give expression to scientific 
progress in the treatment of disease and to 
those advances and activities carried on for 
the protection of the health of the people of 
North Carolina. This new Journal will l)e 
a champion of ideals. It will be a defender 
of those established policies so necessary to 
insure to the people of this great state the 
highest standards of medical service. 

Rock Sleyster, M.D. 

A NEW MEMBER FOR THE 
DISTINGUISHED COMPANY OF 
STATE MEDICAL JOURNALS 
More than twenty-five years ago, when I 
first became assistant to the editor of The 
Journal of the American Medical Associa- 
tion, the state medical journals had already 



begun to adopt scientific and ethical stand- 
ards in relationship to their advertising. 
Few of them, however, were distinguished 
for scientific and editorial competence. More 
and more, as the years have passed, it has 
become apparent that physicians of the con- 
stituent state associations of the American 
Medical Association were beginning to recog- 
nize the importance of the state medical 
journals as leaders in the field of medical 
thought. 

Today there remains but one of the .state 
medical journals which fails to follow the 
standards of the various scientific councils 
of the American Medical Association in its 
acceptance of drugs, foods, and physical de- 
vices which are of known composition or 
contruction, and promoted with established 
claims. 

Moreover, practically all the publications 
which now represent the constituent state 
associations are the property of these asso- 
ciations rather than of any private publish- 
ing agency. With sound scientific manage- 
ment and with the assistance of the Coop- 
erative Medical Advertising Bureau, they 
are published not only without excess cost 
to the state medical associations, but in .some 
instances actually yield a profit, which is of 
service in promoting scientific and public 
relations work of these societies. 

An editor who studies these periodicals 
will realize that they do not follow any fixed 
pattern in composition, makeup, or style. 
They are, indeed, as individual in their ap- 
pearance and in the nature of the material 
which they present as are the states them- 
selves. There is reason to believe that the 
state medical journal of North Carolina will 
be able to reflect as well, the personality and 
the character of the medical profession of 
that -state. North Carolina is also to be 
congratulated on the acceptance of the edi- 
torship by Dr. Wingate M. Johnson, whose 
writings have already received national rec- 
ognition by inclusion in periodicals, both 
jiopular and scientific, of national circula- 
tion. 

North Carolina is welcome to the family 
of state medical journals, coming at a time 
when that family has emerged from its 
original state of poverty and comparative 
illiteracy into an aristocratic assemblage of 
erudite and financially competent journals! 
Morris Fishbein, M.D. 



48 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



CALL THE DOCTOR 

Society is sick, suffering, cold, hungry, 
senile, frightened. Unhealthy desires fanned 
by hot currents of discontent make life in- 
creasingly hazardous. Overactive glands are 
producing a hypertensive, unstable, inflam- 
mable race. Oblique morals, fragile nerves, 
unsound minds, all diseases of civilization 
common to man alone of all animals are fill- 
ing hospital beds. While the same forces 
push some to the frontiers of genius, others 
who are meshed in lower gears bog down to 
dead levels of mediocrity or unemployable 
indigency. 

Fifty years of modern medicine have sal- 
vaged so many that the average life ex- 
pectancy is now sixty-two years. At the 
same time reproduction is attended with 
difficulty. Ten per cent of marriages are 
sterile and there is no evidence that replace- 
ments are of stronger quality. Too many 
young mothers die; too many children fail 
to attain a strong maturity ; too many hearts 
fail to keep step with modern speeds; too 
many malignancies destroy young adults ; 
too many people between the ages of thirty- 
five and sixty-five are limping along with 
incapacities. 

In the midst of this dismal picture occur 
so many colorful stirrings by groups and 
individuals that hope still lives. 

Christopher Morley said recently "One 
astonishing phenomenon has become plainly 
manifest; the obvious reluctance of civiliza- 
tion to tear itself to pieces". "I think it the 
greatest tribute to civilization that if it 
should perish it will do so reluctantly". 

With a promise of recovery it is time to 
call the doctor. If civilization improves the 
doctor will have to do much more than patch- 
work and protective immunization. He will 
have to concern himself with studies of per- 
sonality, psychiatry and eugenics. Genei'a- 
tions of thoughtful mating under the inspir- 
ation of the doctor will surely help; mean- 
while the foundations must be laid by the 
doctor. He must educate youth physically 
and morally. He must be vigilant in help- 
ing the poor to help themselves. He must 
ease the path of low income people without 
lowering their morale. He must fight every 
degenerative disease. He must work out 



formulae for rehabilitating the victims of 
the industrial machine. He must keep him- 
self upon a high plane and he must take the 
directing place in society for which his edu- 
cation qualifies him. His optimism must be 
stimulated by knowledge of the historic fact 
that for two thousand years his predeces.sors 
who swore to carry on the Hippocratic tra- 
dition have survived the rise and fall of 
many civilizations. 

Again and again they have responded to 
the call for the altruism which has preserved 
their identity. The new voice which is to 
speak in North Carolina will be heard by 
many doctors in city and country — let us 
hope that it will awaken them and that they 
will answer the call with all the strength of 
mind and character which they possess. 

Speaking for all whom I may represent I 
welcome the advent of the North Carolina 
Medical Journal most heartily. I am con- 
fident that it will be a great success under 
its so distinguished leadership. 

Nathan B. Van Etten, M.D. 



TELEGRAM FROM DR. OLIN WEST 

The Medical Society of the State of North 
Carolina has taken an important forward 
step in establishing its own .iournal. I am 
sure that the journal will make great con- 
tribution toward the promotion of the art 
and science of medicine and the betterment 
of the public health in your state. I con- 
gratulate the Medical Society of the State 
of North Carolina on having taken this pro- 
gressive step. 

Olin West, M.D. 



THE NATIONAL COMMITTEE FOR THE 
EXTENSION OF MEDICAL SERVICE 

During the "five years of persecution", as 
Dr. Rock Sleyster aptly termed the system- 
atic drive made by the Federal government 
to force some sort of political medicine on 
the people of the United States, the Ameri- 
can Medical Association has often been criti- 
cised by its own members for not fighting 
back hard enough. Many doctors and friends 
of doctors have felt that there has not been 
enough effort made to present the cause of 
organized medicine to the people. This criti- 



^^ 



January, 1940 



EDITORIALS 



49 



cism has had just enough justification to 
give point to Hambone's observation that "A 
lie don't hurt a man as much as when a 
lettle bit of truth git out on him." 

There have been more reasons than were 
apparent on the surface, however, for this 
attitude on the part of A.M. A. officials. One 
reason is that it would have required far 
greater financial resources than the Asso- 
ciation has to combat the unlimited funds at 
the disposal of the government -inspired 
propagandists. Another reason is that for 
the A.M. A. officially to have entered the 
arena of political lobbying would have made 
it liable to the loss of most of its revenue by 
the income tax route. 

The long-felt need for an articulate body 
to fight for the justice of our medical ideals 
in a practical way has been met by the or- 
ganization of the "National Committee for 
the Extension of Medical Services". While 
this group has no organic union with the 
American Medical Association, its executive 
board and central committee are composed 
of men whose loyalty to the cause of organ- 
ized medicine has been tested in innumer- 
able ways over many years. A number are 
past presidents of the A.M. A. The chair- 
man of the Executive Board is that grand 
old war horse. Dr. Edward H. Gary, of 
Texas, for years Chairman of the Associa- 
tion's Committee on Legislative Activities. 

Naturally this group must have money in 
order to carry on its work efl:'ectively. Ap- 
peals are being made to physicians and their 
friends for financial support. Besides giv- 
ing money, doctors and their friends can be 
of great help in fighting the threat of politi- 
cal medicine, by reminding their Senators 
and Representatives that socialized medicine 
was born in Russia and Germany, and was 
the entering wedge for totalitarianism in 
both those countries. 

Let all who are interested in opposing the 
menace of political medicine support in every 
possible way this organization — and thus let 
the people of America know that organized 
medicine is dynamic, not static. 



THE PLATFORM OF THE AMERICAN 
MEDICAL ASSOCIATION 

The charge has been made over and over, 
within as well as without the ranks of the 
American Medical Association, that organ- 
ized medicine has adopted a dog-in-the-man- 



ger policy in the matter of securing a wider 
distribution of medical care to the American 
people. We have been told that, unless we 
have something constructive to offer, we 
should not attempt to obstruct such plans as 
were embodied in the Wagner (so-called) 
Health Bill. 

Whether or not there is any foundation 
for such a charge, it should now, in justice, 
be withdrawn. At the annual meeting of 
the state secretaries of the A.M. A. held in 
Chicago, November 17 and 18, there was 
announced "The Platform of the A.M. A." 
This platform has been given all possible 
publicity, tlirough the lay press and other- 
wise. Most of our readers have seen it long 
ago, and many may have it hanging in their 
offices ; but it will do no harm to reproduce 
it here. 

The American Medical Association advo- 
cates : 

1. The establisment of an agx'iicy of the federal 
government under which shall be coordinated and 
administered all medical and health functions of the 
federal government exclusive of those of the Army 
and Navy. 

2. The allotment of such funds as the Congresb' 
may make available to any state in actual need, for 
the prevention of disease, the piomotion of health 
and the care of the sick on proof of such need. 

3. The principle that the care of the public 
health and the provision of medical service to the 
.sick is primarily a local responsibility. 

4. The development of a mechanism for meeting 
the needs of expansion of preventive medical .ser- 
vices with local determination of needs and local 
control of administration. 

5. The extension of medical care for the indigent 
and the medically indigent with local determina- 
tion of needs and local control of administration. 

6. In the extension of medical .services to all 
the people, the utmost utilization of qualified medical 
and hospital facilities already established. 

7. The continued development of the private 
practice of medicine, subject to such changes as 
may be necessary to maintain the quality of medical 
services and to increase their availability. 

8. Expansion of public health and medical ser- 
vices consistent with the American system of 
democracy. 

It will be noted that every point made is 
positive; there is not a negative note in the 
whole document, yet it represents the con- 
sensus of opinion of the House of Delegates, 
speaking for the 115,000 members of the 
A.M. A. It certainly should put to rest the 
time-honored lie that that body is purely re- 
actionary. 



50 



NORTH CAROLINA MEDICAL JOURNAL 



JanuaiT. 1940 



CASE REPORTS 



A CASE OF AGRANULOCYTOSIS* 

\V. M. B. Brown, M. D. 

Greenville 

The etiology of Agranulocytic Angina is still un- 
known; Kracke and Parker' " have written the 
most comprehensive article on the factors sup- 
posedly concerned in its causation. These two inves- 
tigators emphasize that it occurs mostly in middle 
aged women, was a rarity before 1922, and is i^n- 
known in negroes. They give suggestive evidence 
that a drug containing the benzine ring such as 
amidopyrme, may oe an miportant fai.ior. It is 
also known to occur occasionally in the course of 
prolonged infections V. L. Boltoni-) suggested 
that possibly the granulopenia of Agranulocytic 
Angina is due to transformation products of cer- 
tain drugs which may in susceptible subjects cause 
arrested maturation of the myeloid elements of the 
bone marrow. 

This cace of agranulocytosis is presented to add 
to the series of cas'es th.'t have not taken amido- 
pyrine or barbituaites; the history of the patient, 
patient's family, and the family doctor prove be- 
yond a doubt that she did not take drugs of that 
series. Even when a tooth was extracted she was 
given codeine. Several other case reports give a 
history of having a tooth extracted several weeks 
or months before an attack of agranulopenia as did 
the ease I am reporting. 

The patient was a single, white woman, age 43, 
school teacher. I was asked to see this patient in 
consultation with a local dentist on the morning of 
April 28, 1938, at her home. She gave a history 
of having had a wisdom tooth extracted on January 
14, 1938, and had noticed a !?pur on the gum where 
the tooth had been removed, about two weeks previ- 
ous to my first examination. She returned to her 
dentist one week later and he removed the spur with 
a sharp curette. About three days later the patient 
developed a sore throat which she treated by means 
of home remedies, while continuing to teach. On 
the morning when she was first seen by me, she was 
complaining of s^evere sore throat, high fever, in- 
ability to swallow, and loss of sleep the night be- 
fore. I immediately sent her to Pitt Community 
Hospital and had Dr. D. B. Armistead see her. 

Past history was essentially negative, the patient 
having had the usual childhood diseases. She stated 
that she had felt run down and weak all the winter, 
but had kept on with her work. 

Physical examination showed a white female who 
appeared critically ill and in a state of collapse. 
Respiration was very rapid and labored. Her pupils 
reacted to light and accommodation, and were equal. 
Fundi were normal. Examination of nose and ears 
was negative. Tne entire pharynx and fauces 
showed extremely marked homogenous inflamma- 



*Read before the Section on Ophlhalmolopj- and Otolarvnpo- 
logy of the Medical .*!oriety of the Stale of .N'orth Carolin.-l, 
.May 13. 1939. 

(1) Kracke, R. R., and Parker, F. P.: The Rela- 
tionship of Drug Therapy to Agranulocytosis, 
J.A.M.A. 105:960 (Sept. 21) 1935. 

(2) Bolton, V. L.: Laboratory Study of Amido- 
pyrine. Barbital, Phenyl Hydrazine and Ben- 
zene in Kelation to Agranulocytic .Vnginia, J. 

Ub. & Clin. Med. 20:1199, 1935. 



tion and edema. A grayish-white membrane was 
noted over the left posterior pillar and pharyngeal 
wall. The membrane was friable and easily remov- 
able. The anterior cen'ical glands showed great 
tenderness and swelling. Both the teeth and gums 
were in fair condition. There was no rigidity of 
the neck. Examination of the heart showed apex 
in 5tlt interspace S'2 cm. from mid sternal line; no 
cardiac enlargement; ;rhythm regular, rate 120. 
There were no thrills nor murmurs. A few scattered 
rales were heard over the bases of both lungs. B.. P. 

s^-eo. 

Laboratory examinations were as follows: Spinal 
puncture showed pressure normal and water-clear 
fluid, the cell count being normal. Urine: specfiic 
gravity 1030, acid, 2-|- albumin, occasional W. B. C. 
A blood smear was negative for malarial parasites. 
The hemogloblin was 52';c with red blood cell count 
2,UO0.noO. The leukoc:,tc count was 1,000 with polys 
O, small lymphocytes 30 Tc, large lyphoytes 707c. 
The following day the leukocytic count was 1,600 
with polvs 1^,'l, small Ij-mphs 2G':'c, large IjTnphs 
73 '-f. 

Treatment consisted in the administration of 
parenteral glucose and normal saline, ice collar, 
pantapon for pain, liver exitract, oxygen, blood 
transfusion, and pentnucleitide; however, the patient 
failed to respond and died on the third day after 
admission to the hospital. 

DiscjiXKiuu 

DR. C. N. PEELER (Charlotte): How old was 
she. Doctor? 

DR. BROWN: Forty-three. 

DR. PEELER: That makes me think of one of 
our colored nurses who caught a cold. About two 
months ago, she caught a cold at home and de- 
veloped influenza. She used the home remedies, 
treated herself. She worked for Dr. Bottomley. He 
went out to see her, gave her codeine and some 
aspirin to make her comfortable, and thought she 
would be all right. From the influenza, she de- 
veloped a pneumonia, bronchial type. She had con- 
solidation following that. An internist treated her 
and typed the infection and gave her the s^erum. 
In the meantime, she had had some sulfanilamide 
— I don't think a great amount. Her blood picture 
began to go down — hemoglobin, polys, and total 
white count. Her red count at the beginning was 
good. The white count, something like 15.000. went 
down to 7,000, then to 5,000, and on down to 1500. 
with a decrease in the neutrophils, too. 

All medication was stopped and supportive meas- 
urse used, .sne gradually pulled out of it. her 
white count went to 800, but after two transfusions, 
she finally started to improve. 

CHAIRMAN PEERY: The rarity of agranulocy- 
tosis in the colored race would make one think how 
much that sulfanilamide depressed her. 

DR. PEELER: Whether the sulfanilamide was 
responsible or not was the question. I remembi r 
she had eighty dollars' worth of the serum during; 
the treatment for the pneumonia. 

In that connection, I might report a case of my 
own that I just dismissed a few days ago. Tins 
child was twelve years old, and developed a son' 
throat. She had her tonsils and adenoids. She h;id 
a mild sore throat, and then she developed largi' 
glands on both sides. She was sent in at nine 
o'clock on Sunday night. I couldn't get to do any 
blood work. She had been given five grains of 
sulfanilamide by her family doctor before he sent 
her in. She had a temperature of 104, with a ch;i-ii 
of glands on both sides greatly enlarged. She h;iil 
very little redness of her throat. So I put her on 



January, 1940 



CASE REPORTS 



SI 



sulfapyridine, not knowing the infection. The next 
morning I had a complete blood count made, which 
showed 7800 whites with 78 per cent polys. So I 
immediately cut down my drug. The next morning 
her temperature was around 100; blood picture, 
1700 whites, 18 per cent polymorphonuclears, anil 
her hemoglobin and red cells had decreased a great 
deal. The third morning the white cells were about 
the same — but her polys were 8 per cent. She was 
looking good. Her color had improved. She was 
beginning to eat again and was: sleeping very well. 
The glands of her neck had gone down considerably. 
Next morning her polys, were 4 per cent. We kept 
her in the hospital a week. When she went home, 
her polys were 17 per cent. She came back in a 
week, and the blood picture had improved still more. 
The polymorphonuclears were 27 per cent. I have 
not seen her since. 

It was very interesting to me. She did not get 
a great deal of the dinig, but when she returned a 
week later, she looked like a well girl, except for 
the blood pressure. I follow the rule that I do not 
give powerful drugs', such as sulfanilamide, except 
in the hospital where I can get a picture of the 
blood every day. 



STAB WOUND OF HEART 

A. HiNSON, M.D., F.A.C.S. 

Davis Hospital 

Statesville 

G. M. — Age 28; color, black; occupation, mill 
work. 

present ILLNESS: Patient stated that he was 
stabbed in the upper left chest by a colored man 
ten minutes' before admission. There had been very 
little bleeding from the wound, but he felt very 
weak and had trouble breathing. Patient was con- 
scious and answered questions properly. 

PHYSICAL EXAMINATION: Patient was a very 
apprehensive colored man of 28 years who was hav- 
ing extreme dyspnea. Weight — estimated 160 pounds. 
Blood pressure could not be obtained. Temperature 
98 degrees'. Pulse imperceptible. Scalp and skin 
aparently normal. Lips, tongue and conjunctiva 
cyanotic. 

Ear, Eye, Nose and Throat — Pupils equal and 
regular, and react to light and distance. Mucous 
membranes slightly cyanotic. 

Respiratory System — Respiratory rate 28 per 
minute. Percussion showed an enlargement of the 
entire heart towards the left and right. Pulse was 
imperceptible. Heart sounds were very faint and 
distant. There was a small stab wound in the left 
chest just lateral to the sternum in the 4th inter- 
space with a slight amount of bleeding from the 
wound. 

The abdomen was flat. No masses were palpable. 
No tendernes's was present. 

Nervous system — Patient extremely apprehensive. 
Patellar and biceps tendon reflexes sluggish. 

CLINICAL LABORATORY: 

Fluoroscopic examination of the chest showed a 
pneumothorax to the left with some haziness in the 
lower part of the chest. Heart shadow was gi'eatly 
enlarged and of the water bottle type. In the cen- 
tral portion of this there was a clear area sugges- 
tive of air in the pericardium. There was very little 
motion to be seen in the heart. 

Specimen of urine could not be obtained. 

R. B. C. 4,700,000 

Hemoglobii) 100% 



W. B. C. 13,000 

Polys. 86% 

Lymph. 16% 

Eosinophils 1% 

Myeloblasts 2% 

Patient was immediately typed for blood trans- 
fusion, and 2000 cc. of b'/o glucose in saline was 
given intravenously. 

Electrocardigraphic findings before operation 
showed no definite abnormalities. 

Patient was' taken to operating room immediately. 

OPERATIONS AND FINDINGS: 

Anesthesia: Novocain Solution (local infiltration). 

An oblique incision was made over the 3rd, 4th, 
and 5th costochondral junctions with a convexity to 
the left. The cartilages with the costal muscles 
were reflected medially. It was necessary to frac- 
ture the cartilages at the chondrosternal junction 
before this could be accomplis'hed. Several adhesions 
between the lung and the anterior chest wall were 
ligated. A small amount of blood was evacuated 
from the lower portion of the left chest. A small 
stab wound entering the upper and left portion of 
the pericardial cavity was enlarged and about 100- 
150 cc. of blood evacuated from the pericardium. 
A large intercostal artery was found to be severed 
and bleeding through the lung and pleura into the 
pericardium. There was also a stab wound in the 
heart just below the left auricle which was incom- 
plete in that it did not extend through the endo- 
cardium. The pericardium was tightly distended 
with blood which had compressed the heart. When 
an opening was made into the pericaidium there 
was an immediate escape of blood. The heart rate, 
which had been rapid and of poor quality, immedi- 
ately became slower and took on long, powerful 
contractions. His pulse was immediately felt at 
the wrist. As the heart muscle was not bleeding 
it was felt that only one stitch was necessary. One 
large rubber tissue tubular drain was placed in the 
pericardium and the wound sutured around this with 
plain catgut No. 1. Two rubber tissue tubular 
drains were placed in the pleural cavity and brought 
out through the lower end of the incision. The 
wound was then closed with chromic catgut No. 2, 
re-approximating the cartilages to their normal po- 
sitions. Several silkworm gut sutures were taken 
through the skin and the skin closed with Michel 
clips. Patient was given 450 cc. of citrated blood 
and 1000 cc. of 5% glucose in normal saline intra- 
venously during the operation. 

Electrocardiogram taken immediately after opera- 
tion showed very little change from that taken be- 
fore operation. 

FINAL DIAGNOSIS: 

(1) Stab wound, left chest, 4th interspace, pass- 
ing through lung, pleura and pericardium. 

(2) Stab wound of heart, left ventricle, incom- 
plete. 

(3) Cardiac tamponade from intrapericardial 
hemorrhage. 

(4) Possible pneumopericardium with pneumo- 
thorax. 

PROGRESS NOTES DURING STAY 
IN HOSPITAL: 

There was' a large amount of drainage during the 
first 24 hours. His temperature ranged from 102 
to 103.8. The drainage was of a serosanguineous 
nature. Respiration ranged between 30 and 36 per 
minute. Patient was given two 1000 cc. glucose 
infusions daily for six days. The pericardial drain 
was removed in twenty-four hours and was followed 
by the seepage of 200-300 cc. of serosanguineous 
material. Temperature remained around 102-103 for 



52 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



El- 1 Hs'tiBsU: IJ 1 ' 



apvf^^i 



mim-!r- 



^.(^ 



.-«^^^ 



■ii« W ii i"ni ^^ 



' " » ■ ■»■ • ■ V 



Fig. 



Fig. 1 — Electrocardiograms before and after 
operation. 

eight days. Drainage gradually decreased. The 
pleural drain was removed after six days. Respira- 
tion gradually slowed down to around 26 per minute. 
Pulse retained its good volume from the time of 
operation and remained between 130 and 140 per 
minute for ten days. On April 27th 600 cc. of 
citrated blood was given intravenously without a 
reaction. On April 30th his temperature was 103 F., 
respiration 32. There was dullness over the left 
chest. The chest was aspirated but only 200 ccc. of 
seropurulent material was removed. Following this 
there was an increase of discharge from the drain- 
age wound and an open pneumothorax developed. 
A large amount of fluid of the same nature came 
out of this opening for the next ten to twelve days. 
Cultures from this fluid showed many staphylococcus' 
aureus and streptococcus hemolyticus. The dis- 
charge gradually became thick, yellowish pus. As 
soon as the open pneumothorax developed, one- 
fourth of an ounce of fresh azochloramide solution 
in olive oil was placed in the open cavity every 
four hours with a small syringe. This apparently 
hastened convalescence considerably, because of the 
marked diminution in the amount of discharge. 
There were several abscesses around the stitches 
which were removed on the 12th day. Examination 
of the chest showed a rapid re-expansion of tlie 
left lung but rather distant breath s-ounds with some 
dullness persisting at the base. Condition on dis- 
charge improved. 

FOLLOW-L'P NOTES: 

.May 2.'). 1938: Patient seen at home. Pulse and 
respiration normal. Complains of tight feeling in 
chest occasionally. Appetite good. Small amount 
of drainage from wound. Dressing changed. 

May 30. 1938: Decrease in amount of drainage. 
Patient still in bed most of the day. 

June 7. 1938: Blood pressure 170/90. Weight 
146 pounds. X-ray of the chest showed some hazi- 
ness of the lower portion of the left chest, appar- 
ently due to a thickened pleura in this region. 
Physical examination still showed distant breath 
sounds in this area. No murmurs were heard. Heart 
sounds were rather distant. Kahn test was taken 
at this time and reported as four plus. 0.6 grams 
Neoarsphenamine was given intravenously. Elec- 
trocardiogram at this time showed definite, appar- 
ently temporary, myocardial changes suggesting 



-Electrocardiogram 6 weeks after 
operation. 



marked reduction of myocardial tone from previous 
record. 

June 14, 1938: Dressing changed. Small amount 
of discharge. Slight deformity of costal cartilages 
which were very tirm. They apparently had healed 
well. 0.6 gram of Neoarsphenamine was given in- 
travenously. 

July 1, 1938: Dressing changed. Drainage ceased. 
Patient to do light work. 0.6 gram Neoarsphena- 
mine given intravenously. 

Oct. 28, 1939: Has been receiving antiluetic 
therapy regularly. Chest firm. No discomfort. 
Apparently cured. 




Fig. 3 — Scar of operation. 



IH 



January, 1940 



CASE KEI'ORTS 



S3 



STAPHYLOCOCCUS MENINGITIS 

Report of a Case With Cure 

Robert L. McMillan, M.D. 

Winston-Salem 

From the available details at hand, both in the 
current literature and in various textbooks, the out- 
standing feature of staphylococcus meningitis is 
that the disease is almost uniformly fatal regardles's 
of origin, duration, patient's age, sex, or the treat- 
ment instituted. Only eleven cases have been re- 
ported as treated and cured up to 1939. 

The foUoviring case is presented not with the idea 
of demonstrating a medical rarity, but rather to 
bring forward as a suggestion for further us'e in 
diseases of this type, staphylococcus antitoxin by 
the three main parenteral routes, subarachnoid irri- 
gation, and blood transfusions. 

The effectiveness of staphylococcus antitoxin is 
greatly enhanced by the use of sulfanilamide and 
likely will be more so by sulfapyridine, since the 
latter has been shown to have a very definite 
bacteriostatic action on staphylococci. Also, it has 
been clearly demonstrated in cases of staphylococcic 
bacteremia that blood transfusions greatly increase 
the effectiveness of the antitoxin, and should be 
liberally employed. 

REPORT OF CASE 

P. J. v., a seven year old school girl, was ad- 
mitted to the North Carolina Baptist Hospital May 
10, 1938, having been referred by Drs. Belmont and 
Rupert Helsabeck of King, North Carolina. 

CHIEF COMPLAINT: Pain in the abdomen for 
two weeks. 

FAMILY HISTORY: Irrelevant. 

PAST HISTORY: Normal birth and develop- 
ment. Usual childhood diseases. Generally excep- 
tionally healthy and robust. No operations or in- 
.iuries. 

PRESENT ILLNESS: About two weeks before 
admission the patient complained of occasional gen- 
eralized abdominal pains. She continued at school, 
but ate poorly and did not play as actively as com- 
mon. One week before admission the pains became 
considerably worse and there was nausea and vomit- 
ing. At this time her temperature was 101 F. 
(38.6 C), and there was slight stiffness of the neck, 
which was thought to be meningismus. General 
physical examination was normal except for the 
above, and slight generalized abdominal tenderness. 
Within a day or two the temperature became normal 
and the child returned to school. Three days before 
admission all of the above iymutonis became de- 
cidedly worse and the temperature was found to 
be 103.8 F. (40 C). There was no headache or ear- 
ache and the ears, nose, and throat were normal 
except for slightly enlarged tonsils. 

PHYSICAL EXAMINATION: T. 103.8 F. (40 C), 
P. 96, R. 20. B.P. 100 mm. mercury systolic; 60 mm. 
diastolic. The patient was obviously gravely ill, 
lying on her side in opisthotonic position, her eyes 
shielded from the light, delirious and slightly cya- 
notic. The neck was quite stiff. There was slight 
generalized lymphadenopathy and exquisite tender- 
ness over the lumbar spine. The tonsils were en- 
larged and infected. Heart and lungs were normal. 
There was slight generalized abdominal tenderness, 
but no masses' or localized tenderness. Carnial 
nerves were normal except for choking of the optic 
dis-cs to two diopters. The tendon reflexes were 
over-active but equal. Kernig's sign was present 
right and left grade IV. 

ACCESSORY CLINICAL DATA: Leucocytes 38,- 
250, Polymorphonuclear 96%, mainly adult forms. 



Lymphocytes 4%, Red Blood Cells 4,070,000, Hgb. 
61'/,. cr 15.5 gms. (Saihli^. Spinal fluid 60',i 
solidly purulent material. The first cell count pos- 
sible was 65,000— P.M.N. 99%. L. 1%-. 

IMPRESSION: Meningitis of some type. Due 
to marked tenderness over the lumbar spine and 
signs of meningitis along with abdominal pains, 
Pott's disease was considered; but the x-ray was 
negative. Spinal puncture reavealed thick, tenacious, 
purulent fluid. Smear showed Gram positive cocci. 
Culture showed pure growth staphylococcus aureus. 
The patient rapidly lapsed into unconsciousness. 

TREATMENT: Realizing from past experience 
the futility of treating cases of staphylococcus men- 
ingitis it was decided to use certain precedures, 
which, in the average case of meningitis, have al- 
ways been thought radical and injudicious. With 
the idea in mind of providing adequate drainage, 
frequent spinal punctures were done. For the first 
four or five days it was nece.s'sary to irrigate the 
subarachnoid space with a warm solution of normal 
saline, because of the fact that the spinal fluid was 
too thick to drain through a large spinal puncture 
needle. This irrigation was accomplished by gently 
washing in and out by means of a 20 cc. syringe. 
The sixth hospital day a number 8 uretei-al catheter 
was introduced through a canula into the lumbar 
subarachnoid space. The canula was then with- 
drawn, leaving the ureteral catheter in place to pro- 
vide constant drainage. At this stage the fluid was 
too thick to drain and the catheter was hopelessly 
plugged up after eight hours. Frequent spinal 
punctures with irrigation were subsequently em- 
ployed. In spite of normal otoscopic findings by 
several examiners it was decided to perform bi- 
lateral myringotomy. On the fifth hospital day the 
left eardrum was incised and a large amount of pus 
was obtained containing organisms identical with 
the spinal fluid cultures. Prontosil was given in 
large amounts intramuscularly through the first 
four hospital days, and after this 40 grains of sul- 
fanilamide daily was given by mouth for one week. 
.Seven blood transfusions of 200 to 300 cc. citrated 
blood were given. Also staphylococcus antitoxin 
(Ledcrle) was given as follows: intrathecally, 60,000 
units; intravenously, 100,000 units; and intramuscu- 
larly, 45,000 units, in divided doses. 

The thickly purulent spinal fluid soon became thin 
enough to drain through a large needle and, with 
the use of antitoxin intrathecally, cultures became 
negative in two weeks. The antitoxin was also 
washed back and forth in the subarachnoid space 
following saline irrigation, and the patient was 
placed in Trendelenberg's position for twelve hours 
after the antitoxin was introduced. 

The child's recovery was remarkably rapid. She 
was able to take food, fluids, and medication by 
mouth after the fourth hospital day. She was dis- 
charged from the hospital June 7, 1938. The only 
residuum was mental confusion which was extreme, 
but which seemed to improve gradually, until one 
month after discharge she was apparently normal 
and, in fact, exceptionally bright. Upon her return 
home she developed successively p"elitis, severe ton- 
silitis, and broncho-pneumonia, from each of which 
she made a good recovery. She remembers not one 
detail of her hospital experience. 

This patient must be accepted as a case of 
staphylococcus meningitis completely cured, since 
she has no demonstrable sequelae, has made one 
and one-half years in school with honors, and was 
presented personally to the regular October meet- 
ing of the Noi-th Cai'olina Baptist Hospital in ob- 
vious robust good health, eighteen months after 
her illness. 



64 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



...THE BULLETIN BOARD... 



PRESIDENT'S LETTER 
With the launching of the State Society's 
official Journal, I wish both the editor and 
the Journal a happy voyage. The interest 
and cooperation of our members in the ven- 
ture seem assured. The importance of medi- 
cal journalism in modern medical practice is 
too evident to need elaboration. In school 
we studied books, in practice we study jour- 
nals; the better the journals, the better 
practitioners we are. Whenever we become 
too busy to report our own experience or too 
lazy to learn from the experiences of our 
fellow workers, then we deserve nothing bet- 
ter than the mediocrity which will inevitably 
overtake us. 

William Allan. 



SECRETARY'S MESSAGE 
Our Society has lived well within its bud- 
get for 1939. All obligations for the year 
have been met, leaving the most comfortable 
balance in our history. 

Likewise our membership has reached its 
highest peak. However, there are still over 
four hundred physicians in North Carolina 
who are not members of organized medicine. 
We feel that the Society needs them within 
its fold and that, with the cloud of socialized 
medicine above the horizon, our ranks pre- 
sent the only protection to medicine today. 
To those who are not now members of our 
State Medical Society we extend a cordial 
invitation. 

T. W. M. Long. 



Carolina's New Medical Laboratory and 
Public Health Building 

On December 4 the new Medical Laboratory and 
Public Health Building at the University of North 
Carolina in Chapel Hill was formally dedicated. 
The new building, of Georgian architecture and 
representing a total outlay of approximately $450.- 
000, was nmde possible by a legislative appropria- 
tion and a PWA grant. There are five full floors 
and a sub-basement which house the Division of 
Public Health and the Departments of Pathology, 
Bacteriology, Pharmacology. Physiology, Anatomy, 
and Biological Chemistry. In addition there are an 
auditorium with a seating capacity of approximately 
200, a beautifully designed medical library, and 
modernly equipped animal quarters. 

In connection with the new Medical Building there 
is a dormitory nearby which houses the majority 
of the medical and public health students. As a 
part of the original legislative and PWA grant, a 
new wing has been added to the University Infirmary 
for the development of a small medical dispensary 
in connection with the teaching of physical diagnosis 
in the Medical School. 

At the morning exercises on December 4, pre- 
sided over by Dean R. B. House of the University, 
greetings were brought to the school from Presi- 
dent F. P. Graham: Dr. I. H. Manning, Emeritus 
Professor of Physiology, and for many vears Dean 
of the Medical S-hooI: Dr. William Allan, Presi- 
dent of the State Society; Dr. Carl V. Rcvnolds, of 
the State Health Denartment; Dr. C. C. Carpenter. 
Dean of the Wake Fores-t Medical School; and Dr. 
W. C. Davison. Dean of the Duke Med'cal School. 
The main address of the morning was made hv Dr. 
F. K. Marshall. Professor of Pharmacology at the 
Johns Hopk'ns School of Medicine, on the subiect, 
"Medical Research — The Story of Sulfanilamide." 

At the afternoon session Dr. David Riesman. Pro- 
fpssor Emeritus' of Clinical Medicine and Professor 
of the History of Medicine at the University "f 
Pennsylvania School of Medicine snoke on "The 
Making of a Clinician." Dr. G. Canby Robinson. 
Lecturer in Medicine and Director of the Medical 



Clnnic at Johns Hopkins, spoke on "The Application 
of Medical Science to the Individual." 

Approximately 250 alunmi and friends of the 
Medical School attended a banquet at the Carolina 
Inn in the evening, at which Dr. William Coppridge 
of Durham was toastmaster. The principal address 
was made by Dr. Boudreau, Executive Director of 
the Milbank Memorial Foundation, on, "New Health 
Frontiers." In addition, short talks were made by 
'"•• Victor S. Bryant of Durham for the Trustees' 
1 g Committee; Mr. Stanley H. Wright of the 

P ihn C. Tayloe of Washington, Pi-esident 

of .cal Alumni Association; Dr. J. K. Hall 

of Kn- rinond, representing the Whitehead era of 
the school; and Dr. W. deB. MacNider. 



News Notes from Duke University 
School of Medicine 

On October 14, Dr. Marvin A. Stevens, of the 
Yale Univei-sity School of Medicine, held a clinic 
on athletic injuries. 

From October 19-21 the Annual Post-Graduate 
Symposium on Diseases of the Lungs and Thorax 
was held, in which the following participated: Dr. 
Edward D. Churchill, Dr. Frederick T. Lord and 
Dr. Maxwell Finland, of the Hai-vard Medical School; 
Dr. Daniel M. Bnimfiel, of Trudeau Tuberculosis 
School, Saranac Lake, N. Y.; Dr. Chester A. Stewart, 
of the University of Minnesota School of Medicine; 
Dr. Edward N. Packard, of the New York State 
Hospital for Incipient Tuberculosis, Ray Brook, 
N. Y.; Dr. Cameron Haight, of the University of 
Michigan; Dr. William DeW. Andrus, of Cornell 
University; Dr. Isaac A. Bigger of the Medical Col- 
lege of Virginia: Dr. Charles R. Austrian and Dr. 
William F. Rienhoff, of The John Hopkins Univer- 
sity School of Medicine;; Dr. Dickinson W. Richards 
Jr.. of Columbia University College of Physicians 
and Surgeons; ;Dr. Stuart W. Han-ington. of Mayo 
Clinic: Dr. Daniel C. Elkin. of Emory University 
School of Medicine and Dr. Gabriel Tucker, of the 
University of Pennsylvania School of Medicine. 

On October 21 the Baltimore-Washington Der- 
matological Society met at Duke Hospital. 



January, 1940 



BULLETIN BOARD 



66 



On October 25 Dr. William Allan, President of 
the North Carolina Medical Society gave an illus- 
trated lectui-e on Heredity and Disease. 

On November 14 Dr. Harvey B. Stone, Associate 
Professor of Surgery of The Johns Hopkins Univer- 
sity School of Medicine, held a surgical clinic. 

On December 16 Mr. Charles C. Thomas, Pub- 
lisher, of Springfield, HI., and Baltimore, Md., held 
a clinic for the staff and students on Medical Pub- 
lications. 

On the above date the autumn quarter ended, with 
eighteen seniors completing the medical course, all 
of whom have obtained internships commencing 
January 1, 1940. 



The Bowman Gray School of Medicine 
OF Wake Forest College 

Announcement of the expansion of the present 
Wake Forest Medical School to offer the complete 
four year course, granting the M.D. degree, was 
made on August 6, 1939. This was made possnble 
by funds received through the Bowman Gray Foun- 
dation and by the hospital facilities of Winston- 
Salem, plus the present resources of the two-year 
school. On November 22, 1939, the trustees of the 
college voted to give it the name of The Bowman 
Gray School of Medicine of Wake Forest College, 
when it moves to Winston-Salem. 

Northup and O'Brien of Winston-Salem have been 
selected as architects, and plans are rapidly being 
developed for the construction of the medical school 
building and the additions to the Baptist Hospital. 
Construction will begin in early spring, and it is 
hoped that it will be completed by the opening of 
school in September, 1941. Whether clinical instruc- 
tion will be added by that time will depend on how 
rapidlv the hooitals can be placed professionally on 
a teaching basis. 

The policy of the school will be to offer the most 
modern type of instruction to a selected nam'- 7 

students of ab'Iity and character. The '" k! 

be limited to fifty each. A special eh je 

made to provide an opportunity for a meoL .^eHu- 
cation to students from the rural districts of North 
Carolina, using every encouragement to induce them 
to go ba^k to their home community for the practice 
of medicine. 



Medical Society of South Carolina 

Sesqui-Centennial 

On December 5, 1939, the Medical Society of South 
Carolina celebrated the sesoui-centennial anniver- 
sary of its foundinET. The celebration was held in 
Charleston, where the Society was founded in 1708 
bv a eroup of physicians under the leadorshio of 
Dis. Peter Fayssoux, Alexander Baron, and David 
Ramsay. It was the first permanent medical or- 
canization in Charleston, and for a long time was 
the only medical organization in South Carolina. 
Under its auspices were established a Medical Col- 
lee:e— now the Medical Colleire of the State of South 
Carolina — and two medical journals, the "Carolina 
.Tournal" and the "Southern Medical and Sureical 
•loi'i-nal". Other pro.iefts snonsored by the Society 
included a Botanical Garden, the purchase of an 
auoaratus for the resuscitation of drowned persons, 
and the recording of weather observations. In 1848 
a convention called by the Society formed the South 
Carolina Medical Association, of which the Medical 
Society of South Carolina became a constituent 
member. Dr. James Moultrie was the first presi- 
dent of the new organization, and was later elected 



President of the American Medical Association. 

The program for the sesqui-centennial celebra- 
tion began with a reception at the Gibbes Art Gal- 
lery, where an exhibit of paintings, books, and other 
material related to the early history of the Medical 
Society of South Carolina was opened. This was 
followed by a banquet at the Francis Marion Hotel. 
Addresses of welcome were given by the Hon. Henry 
W. Lockwood, Mayor of Charleston, and the Hon. 
Burnet R. Maybank, Governor of South Carolina. 
A Tablet from the South Carolina Medical Asso- 
ciation was presented to the Society by Dr. William 
Weston, and Dr. Douglas Jennings, president of the 
Association, brought greetings. "An Historical 
Sketch of the Medical Society of South Carolina" 
was given by the president. Dr. James J. Ravenel. 
Dr. Nathan B. Van Etten, President-Elect of the 
American Medical Association, sljoke on "An Ameri- 
can Health Program"; and Dr. Francis R. Packard, 
Editor of the ANNALS OF MEDICAL HISTORY, 
spoke on "Scientific Links between Charleston and 
Philadelphia in the Eighteenth Century". 



North Carolina Pathological Society 

The North Carolina Pathological Society held its 
annual meeting at the City Memorial Hospital in 
Winston-Salem on December 12 at 2:30 p. m. The 
program included papers on: "Possible Relation 
Between Hodgkin's Disease and Brucellosis", by Dr. 
Wiley D. Forbes, Professor of Pathology, Duke 
University; "The Effect of Renal Injury upon the 
Regeneration of Plasma Proteins", by Dr. Russel D. 
Holman, Associate Professor of Patliology, Univer- 
sity of North Carolina; "Illustrative Cases of Un- 
usual Positions of Malignancies", by Dr. L. G. Todd, 
of Charlotte; "Case Reports", by Dr. T. T. Frost, 
Pathologist to the City Memorial Hospital, Win- 
ston-Salem. 

Officers elected for the year 1940 were: Presi- 
dent, Dr. L. C. Todd, of Charlotte; vice-president. 
Dr. W. M. Summerville, of Charlotte; secretary. Dr. 
C. C. Carpenter, of Wake Forest. 



Forsyth County Medical Society 

The annual business meeting of the Forsyth 
County Medical Society was held as a dinner meet- 
ing at the Robert E. Lee Hotel Winston-Salem, on 
December 12, at 6:30 p. m. Dr. Kenneth Lynch. Pro- 
fessor of Pathology at the Medical College of South 
Carolina, spoke on "Pancreatitis," The following of- 
ficers were elected for the year 1940: Dr. B. B. Pool 
president, succeeding Dr. Beverly N. Jones; Dr. V. 
F. Couch, first vice president; Dr. Fred Garvey, sec- 
ond vice president; Dr. P. A. Yoder. secretary; Dr. 
Robert McMillan, treasurer; Dr. J. P. Rousseau, 
member board of censors; Dr. B. N. Jones and Dr. 
V. M. Long, delegates to the state medical society, 
with Dr. P. A. Yoder, Dr. S. D. Craig, Dr. V. C. 
Lassiter, and Dr. S. W. Rankin as alternates. 



Buncombe County Medical Society 

The Buncombe County Medical Society held two 
meetings in December. On December 4, at 8:00 
p. m., the society met at the Citv Hall in Asheville. 
A paper. "Ureent Surerery on Infants", was read 
by Dr. F. Webb Griffith, and a case report, "Pri- 
mary Bronchogenic Carcinoma", by Drs. Margery 
Lord and Donald MacRae, was given. On Decem- 
ber 18, at 6:30 p. m., the society held its annual 
meeting and banquet at Grove Park Inn. 



56 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



Caldwell County Medical Society 

The Caldwell County Medical Society at its regu- 
lar meeting on December 19, was entertained by 
Dr. Verne H. Blackwelder at his residence on South 
Mulberry Street, with a delicious turkey dinner and 
all the trimmings. 

A full attendance was recorded and an enjoyable 
evening was had by all. 

The following officers were elected for 1940: 

President, A. A. Kent, Jr., Granite Falls, N. C: 
vice-president, L. M. Fetner, Lenoir, N. C; secretary 
and treasurer, Douglas Hamer, Lenoir, N. C; dele- 
gate to state medical society, C. R. Hedrick, Lenoir, 
N. C; alternate G. R. Russell, Granite Fall. N. C. 



WOMAN'S AUXILIARY 



Warning to Oculists 

A letter has come from Dr. Herbert C. Kimberlin 
of Trenton, Missouri, requesting that we publish a 
warning to the oculists of North Carolina about a 
crook who has' been operating in Missouri and North 
Carolina. His practice is to pose as a fanner de- 
siring to have erlasses fitted, and to pass a check 
for $.30.00 — usually with a notation for chicken or 
livestock — a.skine for change. He does not call for 
the glasses. The signature and endorsement are 
forced. He has used the names W. C. Curran. J. 
B. Powers. W. C. Cursev. and others. Dr. Kimber- 
lin describes him as being about five feet nine or 
ten inches tall, about 155 pounds, with lieht sandy 
hair, blue eyes, and a smooth shaven, ruddy com- 
plexion. He is also described as having a sandv 
comnlexion and reddish-brown hair, and we'ghine 
about 170 pounds. He gives his age as 4.3 to 49. 
One oculist who examined his eyes reported the fol- 
lowine findinq's: Pupils sinall; distant vision, right 
and left, 20 '16 minus with a correction of onlv one 
quarter diopter astigmatism: axis 86 in right; in 
left the same amount of astigmatism, axis 80. 
Pi'nilarv distance. 64 mm.: temple. 4^2: length, 6U: 
bridp-e height, 2/16: bridge forward, 1/12. 

Th's man has operated in Missouri for a number 
of years, and. in October, 1939, appeared in Gas- 
tonia. N. C. Oculists are asked to be on the look 
out for him, and, should they be given a check by 
such a nerson. to notify the Sheriff of Nodawav 
County, Maryville, Missouri, or the Sheriff of Grundy 
County. Trenton, Missouri, or Dr. Herbei't C. Kim- 
berlin, Trenton, Missouri. 



The Professional Man's Not a "Clock-Watcher." — 

He does not count on regular hours. He realizes 
when he takes up the study of medicine that his 
sleen will often be internipted. that his time will 
not really be his own. and he rejoices to feel that he 
may be called upon when others are in need regard- 
less of h'S own comfort. One other point of dis- 
tinction may be mentioned, and that is the principle 
as laid down in the Hipnocratic oath that he will 
tea'-h this art to others if thev wish to learn 
it "w'tho'it fee or stinulation." The nhys'cipn, and 
indeed anv professional man. should emulate tlie 
Clerk of Cantcrburv Tales of whom Chaucer said: 
"And ^ladlv would he learn and gladlv teach." Win- 
fred Overholser: The Broadening Horizons of Medi- 
cine, Science, 90:2338 (Oct. 20) 1939. 



Officers 

President: Mrs. C. F. Strosnider, Goldsboro. 
President-Elect: Mrs. C. R. Hedrick, Lenoir. 
First Vice President (Organization): Mrs. Joseph 

A. Elliott, Charlotte. 
Second Vice President (McCain Bed): Mrs. Alfred 

A. Kent, Jr., Granite Falls. 
Third Vice President (Loan Fund); Mrs. R. A. 

Moore, Winston-Salem. 
Chairman of Past Presidents; Mrs. P. P. McCain, 

Sanatorium. 
Corresponding Secretary: Mrs. Jack Harrell, Golds- 
boro. 
Treasurer: Mrs. C. E. Judd, Raleigh. 
Recording Secretary: Mrs. J. D. Freeman, Wil- 
mington. 
Chairmen of Standing Committees: 

Mrs. Frederick R. Taylor, High Point, Program. 

Mrs. R. S. McGeachy, New Bern, Research. 

Mrs. Isaac Manning, Chapel Hill, Memorial. 

Mrs. William Earl Overcash, Southern Pines. 
Hygeia. 

Mrs. Sidney Smith, Raleigh, Press and Publicity. 

Mi's. James Buren Sidbury, Wilmington, Public 
Relations". 

Mrs. C. E. Howard, Goldsboro, Scrap Book. 

Mrs. G. Erick Bell, Wilson. Historian. 

Mrs. C. D. Thomas, Sanatorium, Exhibits. 

Mrs. Hamilton W. McKay, Charlotte, Legisla- 
ture. 

Mrs. Thomas Leslie Lee, Kinston, Jane Todd 
Crawford Memorial. 
Councillors: 

First District; Mrs. H. D. Walker, Elizabeth 
City. 

Second District: Mrs. John C. Tayloe, Wash- 
ington. 

Third District: Mis. J. S. Brewer, Roseboro. 

Fourth District: Mrs. M. A. Pittman, Wilson. 

Fifth District: Mrs. W. T. Rainey, Fayetteville. 

Sixth District: Mrs. Ben Lawrence, Raleigh. 

Seventh District; Mrs. Harry Winkler, Char- 
lotte. 

Eighth District: Mrs. Wm. P. Knight, Greens- 
boro. 

Ninth District; Mrs. J. W. Vernon, Morganton. 

Tenth District; Mrs. W. C. Johnson, Canton. 
Advisory Board : 

Dr. Hubert Havwood. Raleigh; Dr. S. D. Craig, 
Winston-Salem; Dr. W. H. Cobb, Goldsboro. 



A MESSAGE TO THE MEMBERSHIP OF 
THE AUXILIARY FROM 
ITS PRESIDENT 
In thinking out my plans and policies for 
the Auxiliary to the Medical Society of the 
State of North Carolina for 1939 and 1940, 
I realize that I am intrusted with the re- 
sponsibility of carrying forward the same 
ideals and high purposes that were born into 
the organization 16 years ago when it came 
into being April 18, 1923, in Asheville with 
Mrs. P. P. McCain as president. It is my 
sincere desire to be guided by these same 
principles during my administration, inter- 
preting them in the light of modern needs. 



January, 1940 



WOMAN'S AUXILIARY 



57 



What we accomiiiish this year depends 
upon the energy and enthusiasm of the local 
auxiliaries, and what you do as an individu- 
al. The slogan for the state ofttcers is : 
"Know your Job and Take Pride in Doing 
It." The state oHicers are well informed on 
their duties, are unselfish, faithful workers, 
and stand ready to help any auxiliary or 
au.xiliary member that calls uiion them. And 
may I urge the auxiliaries to ask them for 
help whenever aid is needed. I call on each 
of you to help earnestly to make 19:50 and 
1940 a most successful year! From time to 
time, I shall ask you to do specific things, 
but I am counting on you individually and 
collectively to support our philanthropies, to 
increase our membership, and to be in- 
formed. 

In fact, my motto for the year is "Be 
Informed and Inform Others". By this I 
mean : 

Know the objectives of (jur auxiliary — 
they give us noble ends to attain. 

Know the history of our organization, 
which gives us pride in its splendid ac- 
complishments and inspiration for fu- 
ture work. 

Know the health laws passed by the 19.'!9 
legislature and what is your part in see- 
ing that they are enforced. 

Kuoir how to discuss socialized medicine 
intelligently in informal groups. 

Know why the Wagner Bill or its suljsli- 
tute if made into law, will not be for 
the best interest of the doctor or the 
public. 

These last three suggestions give us an op- 
portunity to perform a much needed service. 
Realizing that the Auxiliai-y to the Medi- 
cal Society of the State of North (Carolina 
has a big work to do, I am most anxious to 
increase our membership greatly this year; 
the bigger the membership, the bigger the 
job we can do. Last year Mrs. Elliott had 
for her slogan "Every Doctor's Wife a mem- 
ber of Either County or District Auxiliary". 
This is a good slogan, so I am keeping it this 
year, hoping it will be fulfilled; for I would 
like to say personally to each doctor's wife, 
"The Auxiliary needs you and you need the 
Auxiliary". If every doctor's wife knew the 
aims and ideals of the Auxiliary; if she knew 
the need for the work the Auxiliary is do- 
ing; if she knew the worthy iieople without 
means that are nursed back to health on the 
McCain Bed, or the doctor's children who 



have been aided at college by the Student 
Loan Fund ; if she knew the necessity for 
being properly informed on socialized medi- 
cine, health bills, etc. ; if she knew the satis- 
factory friendships that are formed in aux- 
iliary work, and the good times that are en- 
joyed at the local and state auxiliary meet- 
ings; if she knew how her dollar was needed 
and spent, I believe every doctor's wife 
would want to become an auxiliary member. 
My plea is to spread this information and 
double the 1939 membership, which was -1:';"). 
Remember that the organization started 
with a membership of 53 in 1923. I so hope 
every eligible doctor's wife will come into 
the fold before March 15, 1940. 

To stimulate interest in securing a full 
membership this year I am offering a prize 
of $5.00 to be awarded to the district obtain- 
ing the greatest number of dues, on a per- 
centage basis, by May 1, 1940. The di.strict 
which receives the $5.00 will in turn present 
it to the McCain Endowment Fund. Will 
you help your district win this honor'/ 

As you know, we have two philanthropies 
which the Auxiliary sponsors, and which are 
doing a very worthwhile work. The first of 
the.se, the McCain Bed, was started in 1929 
when Mrs. R. S. McGeachy was president. 
The occujjants of this bed are doctors, their 
children, nurses, and other worthy i)ersons 
without funds, who are ill with tuberculosis. 
Our jnirpose is to restore them to health and 
usefulness. Ten patients have used this l)ed 
since it came into being. Funds for carr\-- 
ing on this good work come from 50 cents 
of the dollar dues paid into the Auxiliary. 
May I state here that of the other 50 cents 
of the dues, 25 cents goes to State Head- 
quarters for expenses, and 25 cents to the 
National Headquarters. To be sure of this 
exiien.se money for the McCain Bed, and to 
make the bed a permanent project easily 
financed, the Auxiliary, in 1935, started an 
endowment fund of $10,000. In May, 1938, 
a little over $1,000 of this money had been 
i-aised. Please help toward this goal by .se- 
curing as many subscriptions to Hi/f/cia as 
you can and sending them to Mrs. K. B. Pace, 
State Hyf/cia Chairman, Greenville, N. C. 
The profit that the Auxiliary gets from these 
subscriptions is turned over to the McCain 
FJecF Endowment Fund. And in this fLind 
you have a chance to win another honor. 
Mrs. Kent, State Chairman of the McC'ain 
Bed, is offering a $5.00 prize to the district 



58 



NORTH CAROLINA MEDICAL JOURNAL 



January. 1940 



raising the largest amount of money for this 
purpose. You will hear personally from Mrs. 
Kent in Januarj-. 

I also hope you will be most interested in 
raising money for the Student Loan Fund. 
Jlrs. R. A. Moore, Chairman of the Student 
Loan Fund, is offering a prize of §5.00 for 
the district making the largest contribution 
to this fund. This goal is also §10,000. The 
money, as you remember, is used to make 
loans to doctors' children in their junior and 
senior years at college. Since its organiza- 
tion in 1930, six loans have been made. Mrs. 
Moore has already mailed out a mo.st in- 
structive and appealing letter for this cause. 

My message to you about what has been 
done this year is very encouraging. We 
started off with a most interesting board 
meeting with Mrs. McCain on October 12, 
1939. Mrs. McCain entertained in her usual 
charming and informal manner. The happen- 
ings were interesting and vital to the life of 
our organization. I shall not take the space 
to tell you about the business taken up, but 
please read about it in the minutes which 
will be printed later on in the journal. I 
am very happy to tell you that under Mrs. 
R. S. McGeachy's leadership and at a lovely 
luncheon she gave in New Bern, a new aux- 
iliary of 13 members was formed on Novem- 
ber 2, 1939, with Mrs. McGeachy as presi- 
dent and Mrs. Barker as secretan,-. On De- 
cember 13, I attended a joint meeting of the 
Medical Society and Auxilian- in Clinton, 
in Mrs. Brewer's district. It was a most 
friendly and interesting meeting — a dinner 
meeting with the doctors and an Auxiliary 
business meeting in the home of Mrs. J. S. 
Avers afterwards. They are now engaged 
in getting subscriptions for Hygeio. and 
have their plans all made for a money-mak- 
ing project for the McCain Bed in January. 
I am sure that there are many other inter- 
esting things happening over the state, but 
I haven't, as yet, had a full report from 
them. 

As a final request, may I ask you to get a 
copy of Indu.'itrial Medicine and Surgery 
for the month of October, 1939, and read 
the article on "Socialized Medicine" (page 
423) by Dr. Webb Griffith of Asheville. This 
is an excellent article on the subject and will 
certainly familiarize everyone with the Wag- 
ner Bill. 

I am sure that you, as an auxiliary, are 
as grateful to the Medical Society for this 



space in their ilEDiCAL Journal as I am, 
and I hope you will form the habit of read- 
ing our material from month to month. I 
expect to have articles that will be pertinent 
to our organization, concerning its history, 
the work we are doing, plans for future 
work, and special articles concerning the 
McCain Bed, Student Loan Fund, duties and 
work of special committees, etc. I also hope 
we can give part of this space to items of 
interest from different auxiliaries. 

(Signed) Anna L. Strosnider 

President of the Auxiliary to 
the Medical Society of the 
State of North Carolina. 



3n iHrmortam 



RESOLUTIONS OF RESPECT ON THE DEATH 
OF DR. L. B. McBRAYER* 

We. your committ€e appointed at the Louisville 
meeting to formulate resolutions of respect on the 
death of Dr. L. B. McBrayer, desire to submit the 
following — 

That whereas, an All-wise Providence has seen 
fit to call our Beloved leader and fellow-crusader, 
Ur. Louis Burgin JIcBraver, to his eternal rest on 
April 1, 1938, 

And, whereas, those of us who are left behind 
realize fully the enormous loss sustained in his pa.«s- 
insr by his family, his friends, the Nonh Carolina 
medical profession, the North Carolina Tuberculosi.f 
Association, and the National Tuberculosis Associa- 
tion, as well by the almost limitless other organi- 
zations and inai\nduals with whom he was associ- 
atea and with whom he labored long and so success- 
fully, 

Be it therefore re,<iolved: that we give most sincere 
thanks to our Heavenly Father for this long and 
userul life which was spent by our friend among us; 
tor his outstanding career of leadership in so many 
heids; lor his innumerable qualities of the highest 
type of ability in such a wide-spread area of ser- 
vice to humanity; and above all, for his matchless 
knack of being able with his leadership to inspire 
and stimulate his followers and students to efforts 
which otherwise they would never have been able 
to make. 

And be it further resolved: that a copy of these 
resolutions be inscribed in the minutes of this Con- 
ference, and that copies be furnished the family of 
Dr. McBrayer, the North Carolina and the National 
Tuberculosis Association, and to the press. 
Respectfully submitted, 

(Signed) Paul A. Yoder, Chm. 
Paul H. Ringer, 
Arthur T. McCormiek. 



*.\dopled by unanimous role al llu- .-innual meeting of the 
Suutliern Tuberculosis Conference at CbarlestoD, S. C, 
October «, I99a. 



January, 1940 



IN MEMORIAM 



59 



DR. HENRY BASCOMBE WEAVER 

Our Buncombe County Medical Society grieves 
over th-e loss on February 13, 1938, of its oldest 
member, Dr. Henry Bascombe Weaver. Tempered, 
it is true, by the full measure of his years and his 
honors', our "grief is none the less a real sorrowing; 
it cairies a sense of finality in that his passing 
breaks the last link that connected us with a past 
already remote. 

As in his life were united eighty-si.\ years of 
time that completely bridged an intervening and 
universally recognized era, so in his personality and 
in his practice Dr. Weaver blended the social habits 
and the trends of professional thought of three 
eras. In a word, he was always abreast of the times. 

He was born into a family of peculiar longevity, 
of prominence and wide connections, born into a 
world of pioneering, of horse-back trails and felling 
forests. At an early age he got the best education, 
both secular and professional that the times afforded. 
In the seventies and eighties of the last century he 
carried his heritage of culture and his professional 
skill into every corner of the near-wilderness that 
is now Yancey, Mitchell and Avery Counties. In 
the early nineties he came to the rising city ot 
Asheville, where for nearly fifty years he dispersed 
with unobtrusive gentleness and wisdom that uii- 
describable commodity we know as General Medicine. 
In the nineties he was a member of the young 
State Board of Medical Examiners' which he had 
helped to bring into being. 

He was a reader and a student, and gifted with 
an active mind that kept him in touch with progress 
to the end. An admirable trait was the freedom 
with which he drew upon opinions and skill he con- 
sidered more e-xpert than his own by consultation. 

This sketch would not be complete without a 
word as to his loyalty to the land that bore him. 
Second only to the love of his profession was his 
love of his farm and the music of his hounds. 

To the end that his long life of loyalty and ser- 
vice may be an inspiration and a challenge to 
younger generations, we move, Mr. President, that 
a page of our minutes be devoted to this tribute to 
his memory. 

(Signed) G. S. Tennent, Chairman 
Chas. Hartwell Cocke 
Charles C. Orr. 
***** 

DR. JOHN D. KERR 

Dr. John D. Kerr, Jr., a native and life-long resi- 
dent of Sampson County, N. C, died in James 
Walker Memorial Hospital, Wilmington, N. C, on 
March 14, 1938, Death was the result of injuries 
received in an automobile accident. 

Doctor Kerr was born on the old Ken- plantation 
on Black River in the lower part of Samps'on County 
in 1884. He was the son of John D. Kerr and Susan 
Hubbard Kerr. In 1893 the family moved from the 
plantation to Clinton, where the father engaged in 
the practice of law until his death in 1923. 

Doctor Kerr attended public school in Clinton, and 
the Wright Academy near the forks of Coharie in 
lower Sampson. Later he attended the University 
of North Carolina, and then the University of Mary- 
land. From the latter he was graduated as a Doc- 
tor of Medicine in 1908. 

After serving an internship in a hospital at 
Rocky Mount, N. C, Doctor Kerr returned to Clinton 
and started in general practice. In 1910 he married 
Miss Lovie Pickford, als'o of Clinton, and to this 
union were born six children — three boys and three 
girls. 

In April, 1917, Doctor Kerr entered the military 
service as a first lieutenant in the Medical Corps of 
the United States Army. He served at Camp Se- 



vier, South Carolina, and later with the Thirteenth 
Division in France. After the close of the war he 
returned to this country, and was discharged with 
the rank of captain. He again took up the practice 
of medicine in Clinton, but letained his interest in 
military affairs. In 1923 he was appointed assistant 
surgeon of the 106th Medical Regiment, North Caro- 
lina National Guard, with the rank of lieutenant- 
colonel. This position he held until the time of his 
death. 

Doctor Kerr was a member of the State Medical 
Society, the Independent Order of Odd Fellows, the 
American Legion, and the Presbyterian Chui'ch. He 
was given military rites of burial, the funeral being 
held from the home on March 17, 1938. 

In the passing of Doctor Kerr the state of Noith 
Carolina lost one of its most valued and best-be- 
loved men of medicine. As a doctor he was idolized 
by his patients and held in the highest respect by 
his colleagues. 

(Signed) V. R. Small 

O. L. Parker, 
Committee, 
Sampson County 
Medical Society. 



At a meeting of the Guilford County Medical 
Society held June, 1939, the following tribute, offered 
by Dr. Brockton R. Lyon, was unanimously adopted : 

WASHINGTON JEHU MEADOWS, M.D. 

It is with profound sorrow that we are called 
upon to record the death of Dr. Washington Jehu 
Meadows, a member of this society for many years, 
which occurred at St. Leo's Hospital on April 21, 
1939, from a cerebral hemoirhage. 

Dr. Meadows was widely known, and expressions 
of highest praise for the man and deepest grief on 
account of his death have been universal. 

But mortal memory is a shadow which ([uickly 
fades. Therefore, that those who come after may 
know something of the details of his careei-, and 
the esteem in which we as brother members of his 
profession held him, it is our desire that an endur- 
ing record be presented in the archive.*? of this 
society. 

Dr. Washington Jehu Meadows, son of Warner 
William and Mary Hubbard Meadows, was born in 
Chambers County near Lafayette, Alabama, on the 
29th day of December, 1871. His early education 
was obtained in the Chambers County Schools, fol- 
lowed by his graduation from Lafayette College in 
1891. He then attended Alabama Medical College 
at Mobile and was graduated with the degree of 
Doctor of Medicine in 1894. For several years he 
practiced in Longdale, Alabama, which was followed 
by a year of post-graduate study in New York City. 
Dr. Meadows then moved to Gieensboro in the 
spring of 1898, and continued the active practice of 
medicine until his death. 

In 1895, he married Minnie Pinkard, of Clanton, 
Alabama. This union was blessed with two chil- 
dren who survive him : a daughter. Marguerite 
Meadows McKee, and a son, Julian Meadows. His 
brother. Dr. Willis H. Meadows, his sister, Mrs. 
Dora Still, and his granddaughter Jean Evans Mc- 
Kee. also mourn his loss. 

Dr. Meadows dedicated him.self completely to the 
practice of his chosen profession, although in his 
bus'y life he enjoyed social companionship and found 
time for helpful activity in the civic and religious 
life of his chosen city of Greensboro. He efficiently 
served as President of the Guilford County Medical 
Society, and gave unstintingly of his skill and wis- 
dom while serving on the staffs of the various local 
hospitals. 



T 



60 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



Our lamented member and friend was most 
energetic and progressive, always showing a help- 
ful and friendly interest in the younger men who 
were entering practice — absorbing new ideas and 
new methods from them and giving them the bene- 
fits of a wisdom which could come only from long 
and broad experience. 

Dr. Meadows applied himself most intensively to 
his practice, and his assiduous industry might make 
his name synonymous with "hard work", unless we 
agree with Sir James Bariie; "Nothing is really 
work unless you would rather be doing something 
else". Dr. Meadows loved the practice of his pro- 
fessfion so greatly that, measured by Barrie's stand- 
ard, his tremendous activity could not have been 
"work" to him because there was nothing that he 
liked to do more. 

In addition to being blessed w-ith a powerful 
physique and an active and capacious mind, he had 
a way of winning people to him, and during his 
more than four decades of practice in this com- 
munity, there were few homes that were not graced 
by his presence at one time or another. 

We feel keenly the loss of so great a friend. 
His character and his ideals will ever be an inspira- 
tion in strengthening and expanding our profession- 
al activities. 



DR. JOHN B. WATSON 
Bij Hubert A. Rnijster, M.D. 

Dr. John Blois Watson was born January 2, 1885, 
in Raleigh, N. C, the son of James R. and Lizzie 
King Watson. His grandfather was Dr. David Wat- 
son, and his great grandfather Dr. Robert Watson, 
both of Chatham County, N. C. 

After studying pharmacy and practicing as a 
druggist for some years he entered the University 
of North Carolina Medical School and graduated at 
Raleigh with the class of 1908. He served an in- 
ternship at St. Leo's Hospital in Greensboro, N. C, 
and located in Raleigh for the practice of his pro- 
fession. 

In 1912, 1915, and 1910 Dr. Watson took .special 
courses in infant feeding, physical diagnosis, and 
clinical medicine at the New York Post-graduate 
Hospital. In addition to his private practice he 
taught pharmacy and pharmacology at the old 
Leonard Medical School for Negroes at Shaw Uni- 
versity in Raleigh, and was a member of Rex and 
St. Agnes Hospital staffs. On December 27, 1920, 
he was married to Miss May Greenfield of Kemers- 
ville, N. C. 

Dr. Watson was a Mason, a member of the Ra- 
leigh Academy of Medicine, the Wake County Medi- 
cal Society, the North Carolina Medical Society, the 
Southern Medical Association, and the American 
Medical Association. 

In 1929 he developed a septic endocarditis which 
so impaired his health that he was obliged to give 
us his practice. On July 15. 1938, he died in Raleigh. 

This bare outline of Dr. Watson's comparatively 
short life by no means gives a complete or even 
adequate conception of his chaiacter and his attain- 
ments. He w-as a steatifast, reliable friend and 
companion. His career as a pharmacist, which 
finally led to his desire to study medicine, was built 
upon scientific rather than commercial instincts. 
The writer can testify to his success as a medical 
student. He was ardently interested, accurate in 
his thought, and ambitious' to excel. A general 
average of ninety-two attained by him throughout 
his medical course was sufficient evidence of his 
studious habits and his application to work. 

In his practice Watson was especially interested 
in gastro-enterology, and advanced to a high degree 



of efficiency in that branch of medicine. He was, 
however, a well-rounded medical man, skilled in 
diagnosis and therapeutics. Whenever consultation 
was needed, no matter what the type of case, he 
was ever prompt to call upon his associates. It is 
known that patients with intussusception and 
strangulated hernia owe their lives to his having 
referred them for assistance within the hour of 
recognition; and at least two women are living to- 
day, twenty years after operation for cancer of the 
cervix, due to Dr. Watson's early diagnosis and his 
immediate reference of their cases. 

Of a kind, sympathetic disposition. Dr. Watson 
was' beloved by his patients and his friends. Natur- 
ally he was conservative, quiet and ever reserved in 
manner, but was always genial and communicative 
to his intimates. On account of his prolonged period 
of ill health and his consequent early retirement, 
he was known to few of his younger colleagues. 
His contemporaries and his teachers will remember 
him with admiration and regret his untimely pass- 
ing. 

***** 

DR. ROBINETTE BURNS HAYES 

Dr. Robinette Burns Hayes was born on January 
10, 1877, at Hillsboro. He was the son of William 
A. Hayes and the former Susan Burns Beard. He 
attended private schools at Hillsboro, and became 
a licensed pharmacist in North Carolina and Georgia. 
Later he took up medicine, and graduated at the 
University of Maryland Medical School in 1906, as 
University Prizeman. He interned at the University 
of Maryland Hospital in 1906 and 1907. He practiced 
medicine in Baltimore from 1907 to 1910, and in 
Favetteville, from 1910 to 1917. He joined the 
A.E.F. in 1917, and was discharged in 1919. While 
in the A.E.F. he attained the rank of captain. 
Leaving the anny he took up the practice of medi- 
cine in Hillsboro, and did general practice there 
until the time of his death. 

He was a member of the Durham Orange County 
Medical Society, the North Carolina Medical Society, 
the American Medical Association, the Theta Kappa 
Psi Fraternity (served as President in 1910), the 
American Legion, and the Saint Matthews Episcopal 
Church. 

In 1910 he married Minnie Boyd Anderson, of 
Maryland. To this union was bom one son, William 
Anderson Hayes, and one daughter, Agnes Robinette 
Hayes. 

Dr. Hayes fulfilled the requirements of a real 
doctor. He knew the science of medicine and the 
art of medicine, and he practiced both of them. 
He had an innate sense of justice and of democi-acy 
which made him minister to the poor and needy 
without any regard for his own financial gain. He 
believed that a principle was worth fighting for; 
yet he was amenable to reason. He was a most 
courteous and kindly person. 

To sum up — and we admit frankly that anything 
we wi-ite will be far short of the real Dr. Hayes^ 
he was loyal to his friends, skilled in his profession, 
and firm in his convictions. 

It is fitting to say here that the last illness he 
diagnosed was his own. Before his operation he 
told the doctors attending him just what he had. 
His diagnosis was completely confirmed at the oper- 
ating table. He did not rally as he should follow- 
ing the operation. He realized that he was going 
to die, and he faced death as fearlessly as he had 
faced life. He died on July 16, 1938. 
Submitted by: 

S. D. McPherson. M.D. 
Raney Stanford, M.D. 
Bryan N. Roberts, M.D. 



January, 1910 



IN MEMORIAM 



61 



JACOB FRANKLIN HIGHSMITH 

Jacob Franklin HighsTiiith was a builder. There 
is always in all civilized society a small minority 
which take the lead in creating, improving, building 
up, that life may he made better for themselves, 
their children and their fellow men. J. F. High- 
smith was preeminently one of this minority. 

He was born near Roseboro, North Carolina on 
September 1, 186S, the s'on of John J. and Mary 
Ann Fowler Highsmith of Sampson County. He 
entered Wake Forest College and took the regular 
course there; later he went to Jefferson Medical 
College where he graduated in medicine. He lo- 
cated in Fayettevillc in October, ISS'.), and was en- 
gaged in general practice until lltOli. In November, 
1S89, he married Marv Lou White of Sampson 
Count.v. They had eight children: Dr. J. D. High- 
smith, Mrs. E. J. Wells, Mrs. Anine Campbell. Mrs. 
Louise Hardy, Miss Juanita Highsmith. Dr. J. F. 
Highsmith, Jr., Dr. W. C. Highs'mith, and Mrs. John 
Caldwell. 

In his youth a man of dauntless ambition, he 
finished his course "with most of these ambitions 
satisfied. He had achieved the front rank of his 
profession; he had administered relief and healing 
to untold thousands" along the way; he had founded 
the first private hospital in his state and had 
sustained and moulded it into a great institution 
for the alleviation of human suffering; and at the 
same time he had been a vital part of his com- 
munity in all its ti'uer phases, religious, civic, 
political, and business. 

Fewer men, if any, did more for the establish- 
ment of sound medical and surgical practice than 
did Dr. Highsmith. He served as president of the 
Cumberland County Medical Society, president of 
the North Carolina Medical Society and former 
member of its Board of Medical Examiners, and at 
the time of his death was president of the Tri-State 
Medical Society. 



DR. CHARLES TORRENCE NESBIT 

Dr. Nesbit was born in Westernport. Maryland, 
in 1870; and he passed away at his home at Brad- 
ley's Creek near Wilmington, on October 10, 1938. 

Dr. Nesbit received the degree of Doctor of Medi- 
cine at Baltimore Medical College in ISil.i and in- 
terned in Bellevue Hospital in New York City. He 
also .studied in Europe. He came to Wilmington in 
1907 and did private practice here until he was 
elected as the first health officer of the Consoli- 
dated Board of Health of New Hanover County in 
1911. Aftei' a constructive and successful term of 
office in this organization ho went to Akion. Ohio, 
to become health officer in that city, where he 
served siiccessfuUy until 1920. 

Immetliately following his scivice in Akron. Dr. 
Nes'bit was commissioned as an officer in the Uniteil 
States Public Health Service and was assitned lo 
duty in Des Moines, Iowa, where ho specialized in 
nervous and mental diseases. In 1922 he resigned 
this position to engage in private practice in Chicago. 
He remained there until 1924. wdien he came back 
to Wilmington to resume his practice here, con- 
tinuing the specialty of nervous and mental dis- 
eases. 

Dr. Nesbit's work as health officer in New Han- 
over County was a tremendous undertaking fr(nn 
its beginning; but he had the knowledge, the ability. 
and the courage to carry it on successfully and to 
establish a strong foundation for its future de- 
velopment. At this point I can do no better than 
to quote in full the editorial appearing in the Wil- 
mington Morning Star on October 11, 1938: 

"Charles' Torrence Nesbit was at once a 



scientist and a philosopher who practiced his 
profession according to his own mind and smiled 
with amusement at those who differed. As a 
health officer he left behind a lasting monu- 
ment in the simple fact that he transfornied 
Wilmington from an un.sanitary shamble into 
one of the cleanest cities' in the south. Inci- 
dentally he banished typhoid and similar mala- 
dies that spawned in filth and started Wilming- 
ton on the way to Itealth consciousness. An 
astute gentleman he moved through life with- 
out ostentation and left behind him a record of 
constructive service". 

It is a source of gratification to the many friends 
of Dr. Nes'bit that he lived to see his ulans for 
Wilmington's health program fulfilled. His heroic 
efforts to this end were rewarded by the accomplish- 
ment of his ideals, and the generation unborn when 
he began his work here arc, with their children, 
reaping today the benefits of his faithful service. 

A pioneer health officer in North Carolina, he 
won the esteem of his co-workers here and of the 
entire medical profession in this .State as' well as 
in Ohio. His achievements in the United States 
Public Health .Service were outstanding, and he has 
left an example that mav well be emulated. 

Dr. Charles Torrence Nesbit's remains lie in Oak- 
dale "where the winds and the sea sing his requiem 
and shall forever more": but his name and his 
works will long be remembered in this community 
that he loved and served so faithfully and so well. 
Committee: 

John B. Cranmer, M.D. 

Avon H. Elliott. M.P. 

W. Houston Moore, M.D. 



DR. W. C. ASHWORTH 

Dr. Walter Clark Ashworth was born in Ran- 
dolph County September 7, 1868, and died in the 
Wesley Long Hospital at Greensboro. N. C. on 
December 16. 1938. Funeral services were held at 
West Market Street Methodi.st Church in Greens- 
boro by his pastor. Dr. J. B. Ci-aven, and interment 
followed in Greene Hill Cemetery. 

Dr. Ashworth took his course in medicine at the 
Ohio Medical College in Cincinnati and at the Col- 
lege of Physicians and Surgeons in Baltimore, Md. 
He did general practice at Kernersville, N. C. for 
eight years. He then became interested in mental 
and nervous diseases. an<l took suecial courses in 
this specialty at the New York Polyclinic. 

He moved to Greensboro. N. C.. in 1908 and 
established the Glenwood Park Sanatorium for 
Nervous and Mental Diseases and Drug Addictions, 
and was owner and manager of this institution at 
the time of his death. In 1904 he was married to 
Miss Berdie Sapp of Kernersville, who survives; and 
to this union two daughters. Mrs. Andrew Joyner 
of Greensboro, and Mrs. F. B. Morris, of Winston- 
Salem, survive. 

Dr. Ashworth was a member and ex-president of 
this society, and a member of the North Carolina 
Medical Society, the Tri-State Medical Society, and 
the American Medical Association. None among us 
was more active in the work of these societies. 

Your Committee on Obituaries begs leave to sub- 
mit tht? following resolutions: 

That, whereas it has pleased Almighty God 
to call unto Himself, into that larger and bet- 
ter life, the soul of our beloved brother. Dr. 
Walter Clark Ashworth; and. whereas the re- 
moval of this our friend and brother from the 
snhere of his activities among us leaves a dis- 
tinct sense of sorrow and bereavement. 

Be it resolved that we fellow members of the 



62 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



Guilford Countj' Medical Society, of which he 
was an active member and an ex-president, de- 
sire to give this fitting expression of our appre- 
ciation of his high character and of his long 
and devoted life of service in his chosen pro- 
fession, and 

Be it further resolved that these resolutions 
of respect be inscribed upon the permanent 
records of our society and that a copy be sent 
to his family and to the press. 

(Signed) G. W. Banner 
S. R. Cozart. 



DR. A. C. EVERETT 
By Dr. W. D. James 

The death of Dr. Arey Covington Everett of Rock- 
ingham. December 26, 193S, was of major signifi- 
cance and sorrow among the physicians and people 
of Richmond County and throughout the state. In 
his nassing there has' been removed from our midst 
a physician, who for forty-one years typified and 
represented the o'oneer doctor whose life and work 
was characterized by humility, sincerity, kindness, 
and faithfulness. 

Dr. Everett was born in Laurinburg, November 
20. 18V.3. and wps edu'^ated at the famous Ouacken- 
bush School in Laurinburg and at Oak Ridge, and 
wasr g-raduated from the Univei"sity of Marvland in 
Med'cine in 1897. He nracticed in Rockineham and 
its vicinity from the time of his graduation until 
his death. 

The Richmond County Medical Society honored 
him with the office of secretary-treasurer for fortv- 
one vears. .4t each annual meet'ng for the election 
of officers, he would hand in his resignation, but 
this was never accented. As secretary-treasurer of 
this organization for this length <*f time, his honesty, 
tact, and resourcefulness were never questioned. At 
various times he served as nresident of the County 
Society and of the Fifth District Medical Society, 
proving his ability as a leader. He was al?o a 
member of the North Carolina State Medical Society, 
the Tri-State Medical Society, the Southei-n Medical 
Societv. and was a Fellow of the American Medical 
Association. 

Dr. Everett came from a sturdy family with a 
rich heritage. His native and acquired qualities 
peculiarly fitted him for his profession. He had a 
strong, pleasing personality and a lai-ge, loving, 
courageous heart. He was alwavs' deeply interested 
in his practice of medicine, and ardently took the 
opportunity to help all who suffered. He was a 
friend to everyone. For prompt attention to calls, 
whether from rich or poor, none excelled him. The 
influence of his work is far-reaching, for he never 
denied any worthy cause. 

Even though he had not been in the best of 
health for several years, he led a busy, active pro- 
fessional life up until the day he died. He spent 
Christmas day quietly in his home with family and 
friends, and on Christmas afternoon suffered a heart 
attack. He passed away during the night. With 
sincere sorrow and grateful remembrance, his 
friends and members of this profession record their 
deep appreciation of the life and labors of this de- 
voted Christian physician, who spent his whole life 
in ministering to suffering humanity. 



DR. J. H. BOYLES 

Funeral service for Dr. Joseph Henry Boyles, of 
1710 West Market Street, whose death occurred 
January 24, 1939, at Piedmont Memorial hospital, 
was held January 26, 1939, at 3:30 o'clock in West 
Market Street Methodist church by his pastor. Dr. 
J. B. Craven. Interment followed in Forest Lawn 
cemetery. 

Joseph Henry Boyles was bom in Union county, 
the son of Rev. W. M. and Susan Boyles. Septem- 
ber 27, 1873. After attending public schools and 
old Trinity, he took a medical course at the Uni- 
versity of North Carolina. For a time prior to 
this, he was with the Odell hardware company, and, 
during the Spanish-American war, was in service 
in Cuba and the Philippines. Later he worked and 
studied in St. Luke's hospital. New York, and at- 
tended the College of Physicians and Surgeons in 
Baltimore. Completing his period of internship, Dr. 
Boyles returned to Greensboro, and was for a time 
associated with Dr. E. L. Stamey in the practice 
of Medicine. Later he was associated with Dr. J. 
W. Long in the operation of Greene Street hospital. 
Since that time, he has been activclv engaged in 
practice. 

About 12 years ago Dr. Boyles. associated with 
Dr. A. F. Fortune and Dr. J. G. Thomas, founded 
the Clinic hospital, now Piedmont Memorial hospital. 
He continued actively associated with the institution 
as a member of the medical staff, and was a leader 
in the development of the institution into a vital 
factor of community life. 

Dr. Boyles had long been a member of the Guil- 
ford County Medical Society, the North Carolina 
Medical Society, and the American Medical Asso- 
c'ation. He w-as also a member of Percy Gray camp. 
United Spanish War Veterans, John Wesley Long 
Post, and Veterans of Foreign Wars. 

Surviving are his wife, formerly Miss Ruth Sterne, 
Greensboro: one son, J. Henry Boyles. Jr.; two 
brothers, Frank C. and Marvin M. Boyles: and one 
sister, Mrs. Blanche Carr Sterne, all of Greensboro. 
Your Committee on Obituaries begs leave to sub- 
mit the following: 

In the passing of Dr. J. Henry Boyles, Greens- 
boro and the community lose one of those citi- 
zens whose obituary is most eloquently written 
in the record of their lives. 

Dr. Boyles. veteran physician and surgeon, 
devoted his life to giving of encouragement, 
his personality, his strength and his skill wher- 
ever they were needed. That in the following 
of this career of humanitarian service he found 
time to join in the establishment and manage- 
ment of a hospital, to serve his country and to 
take a prominent part in church and cnmmunity 
activities offers but further testimony to his 
usefulness. It is thus left to us merely to join 
with those whom he served, the community in 
which he exerted his influence, in appending a 
final *Svell done" and in giving thanks for the 
ministrations which he rendered, and the spirit 
which he manifested among us. It is especial- 
ly sad when those who administer to others' 
ills are themselves claimed: but. withal, there is 
corollary emphasis upon eternal values and in- 
destructible rewards. 

Be it resolved that we fellow members of the 
Guilford County Medical Society, of which Dr. 
Boyles was an active member, desire to give 
this fitting expression of our appreciation of his 
high character and of his long and devoted life 
of service in his chosen profession, and 

Be it further resolved that these resolutions 
of rcsDe"t be inscribed upon the permanent 
records of our Societv and that a copy be sent 
to his family. (Signed) S. R. Cozart. 



January, 1940 



IN MEMORIAM 



83 



DR. JOHN BERRY 

Dr. John Berry, a member of this society., and 
for a number of years a prominent practitioner 
among us, passed away in his home at Southern 
Pines, May 25, 1939. He had been in ill health 
for several years and had retired from active 
practice. 

Dr. Berry was born in Hillsboro. N. C, March ;)1, 
1885, a son of the late Dr. John Berry and Mary 
Strayhorn Berry. His father was valedictorian of 
his class at Wake Forest, was* a graduate of Jeffer- 
son Medical College, and served as surgeon to the 
42nd Mississippi regiment, with the rank of captain. 
He did general practice at Hillsboro, N. C, and was 
well known to many of the older practitioners of 
this state and community. His mother, a member 
of an old and esteemed North Carolina family, was 
graduated from Edgeworth Seminary of Greensboro 
in the class of 1872. 

Dr. Berry received his early education at Hart 
School, Hillsboro, and Clemson College in South 
Carolina; spent four years at the University of 
North Carolina (Chapel Hill), two years of which 
were devoted to the study of medicine; and was 
graduated second in his class at Jefferson Medical 
College in Philadelphia, 1908. After serving as in- 
teme at the Philadelphia Polyclinic following his 
graduation, he was appointed to the staff of the 
Pennsylvania State Tuberculosis Sanatorium, located 
at Mount Alto, Pa., and later was appointed deputy 
director of this institution. At the outbreak of the 
World War he volunteered his services and was 
appointed a first lieutenant, later being promoted 
to captain and major. A break in his- health forced 
him to give up this work and he was given an 
honoi-able discharge. 

After a period of rest and recuperation he came 
to Greensboro, and soon was able to build up a 
very active and lucrative practice. He was an able 
practitioner, with a genius for going into the details 
of every case and ferreting out those obscure sym))- 
toms that so frequently confront us. No phy.s'ician 
in our niidsst enjoyed the confidence and esteem of 
his patients to a greater degree than did Dr. Berrv. 

On April 21, 1924, Dr. Ben-y was maiTied to Miss 
Mary Strudwick of Greensboro, daughter of the late 
Judge and Mrs. Robert C. Sti-udwick of this city. 
To this union were born three children. Harriet, 
John, and Mary. Han-iet died in early childhood. 

While Dr. Berry lived in Greensboro, he was an 
active member of this s'ociety until his health failed, 
some four or five years ago, and he was forced to 
retire from active practice. He moved to the Sand- 
hills, hoping there to regain his strength and be 
able to return to Greensboro and resume the work 
in which he was so interested and to which he had 
devoted his time and talent. 

Funeral services were held at his residence in 
Southern Pines Saturday, May 27th, 1939, and ^^■ere 
attended by a large concourse of devoted friends. 

In the passing of Dr. Berry this society has lost 
an able, conscientious and devoted member: this 
community, a painstaking and capable physician: 
and all of us who were privileged to know him. feel 
that we have lost a sincere and valued friend. 

Therefore be it resolved that this sketch of the 
I'fe of Dr. Berry be spread upon the minutes of 
this society, a copy sent to the family of the de- 
ceased, and a copy to the Chairman of Obituaries 
of the State Society, to be included in their annual 
report. 

(Signed) C. W. Banner, Chm. 
S. R. Cozart 
J. W. Slate, 

Obituary Committee. 



BOOK REVIEWS 



LEUKEMIA AND ALLIED DISORDERS. By 

Claude E. Forkner, M.D.. Assistant Professor of 
Clinical Medicine, Cornell University Medical School 
and Assistant Attending Physician, New York Hos- 
pital. Cloth. Price, $5. Pp. 333, with 73 illustra- 
tions in black and white, and 7 in color. The Mac- 
millan Company, 1938. 

This is a comprehensive monograph on leukemia 
which collects together in one volume all that if 
known about this group of diseases. The pathologic 
physiology of the blood and blood forming organs 
and its bearing on the structure and function of 
the organism as a whole is given particular con- 
sideration. The author states that, "this is the 
first attempt, in a comprehensive way, to coiTelate 
the factors of altei'ed structure and function with 
the clinical manifestations of the disease." About 
1600 references are cited in the text and listed at 
the end of the book, occupying a section of 54 
pages. These references include all the work of 
any value that has ever been published on the sub- 
ject, beginning with the first reports of the disea.se 
bv Craigie, Bennett and Virchow in 1845. The table 
of contents and index are especially complete. One 
long chapter discus.scs the changes found in the 
various organs and organ systems. The chanter on 
tieatment is comprehensive, and includes and evalu- 
ates every form of treatment that has ever been 
tried. In addition to the leukemias a large number 
of disorders, frequently considered separately, but 
bearing various relations to leukemia, are presented. 
These include reticulosis, reticulo-endotheliosis, 
pseudo-lei'kemia. leukemia, chloroma. lenko-sar- 
coma. and leukemoid states. The book is truly com- 
prehensive and should be in the possession of every- 
one interested in disorders of the blood. 

RECENT ADVANCES IN HEMATOLOGY. Bv 

A. Pincy. M.D.. Ch.B. (Birm.). M.R.C.P. (Lond.). 
.•\s-sistant Physician, St. Mary's Hosoital for Women 
and Children. London. Fourth Edition, Pp. 312. 
with 8 coloured plates and 34 text figures. Price. 
iSS. Philadelphia: P. Blakiston's Son & Co., Inc., 
1939. 

This book has been almost entirely re-written 
since the last edition in 1931. It is more than a 
review of the recent knowledge of hematology, as 
many well known facts are included as a background. 
The book therefore deals with the present position 
of hematology as well as the recent advances in 
our knowledge. It begins with a study of the cir- 
culating cells, their ancestors, and the organs in 
which they are formed. The pathological changes 
which occur are then taken up in considerable de- 
tail, and most of the book is devoted to these 
changes. The author presents his own belief that 
megaloblasts occur in post-embrvonic life not as a 
normal part of maturation of n-d cells, but onlv as 
an abnormal response of the hematopoietic system, 
in the nature of a revers'on to the embryonic tvpi-: 
however, he cives full attention to the most widely 
held views. The reviewer sees no good reason for 
:i-isum'nsr that the stages of blood cells in fmbryonic 
life differ niatprially from the stages of develon- 
nient in the iidult. even thoue-h there are marked 
changes in the place of origin of different cells. 
The section on Ineffective Leukocytosis, after a dis- 
cussion of the general principles of leukocytosis, has 
a number of pages devoted to specific changes 
found in various diseases. The leukemias and ane- 
mias are adequately discussed as well as the re- 
lated diseases of the blood-forming organs. Through- 
out the book the author warns against imagining 



64 



NORTH CAROLINA MEDICAL JOURNAL 



January, 1940 



"that there arc, so to speak, a definite number of 
'diseases', some of which still await discovery. In 
this sense there are no 'diseases'; there are only 
reactions, some of which, on account of their regu- 
larit.v. can be grasped as a sort of conceptual unity; 
but that does not entitle theiu to be regarded as 
self-existent entities — as diseases". This is a valu- 
able book. The color plates are good, and the illus- 
trations are clear and well chosen. There is a 
glossary at the end of the book and a list of refer- 
ences at the end of each chapter. This book has 
apparently been designed for the general practi- 
tioner, as the various disease states are fre<iuently 
illustrated with case reports. 

THE CLINICAL DIAGNOSIS OF SWELLINGS. 

By C. E. Corrigan, M.D., F.R.C.S. (Eng.). Lecturer 
in Surgery, University of Manitoba, Assistant Sur- 
geon and Director of the Out-Patient Department, 
St. Boniface Hospital. Price, $4. Baltimore: The 
Williams & Wilkins Company. 1939. 

In this day of highly specialized laboratory pro- 
cedures it is stimulating to find a book which is 
concerned with diagnosis by clinical methods alone, 
without any dependence on laboratory work. Diag- 
nosis is essentially an art, and the examiner him- 
self rather than his laboratory aides must forever 
remain the final master of the court of medical de- 
risions. The basis upon which this book is written 
is well expressed in the beginning of the first chap- 
ter as follows: "When attacking any problem it is 
first necessary to marshal all facts, weed out those 
that are non-essential or spurious and then proceed 
to deduce the solution from one's knowledge of the 
subject. Now the facts in this case are the physi- 
cal signs and their elicitation demands training and 
experience. Fortunately however, there is no need 
to review the signs critically — all may be accepted 
as genuine. It is this note of authenticity that 
renders the problem delightful, particularly when 
contrasted with the interpretation of symptoms. All 
the bogeys of exaggeration, minimizing, dramatiza- 
tion and language difficulties which so frequently 
color the patient's complaints, are excluded from 
the nicture. No matter who the patient, his swell- 
ing is more eloquent than his tongue. Can we but 
learn to converse in the language of physical signs 
which are so devoid of duplicity, the meaning or 
nature of the lump will usually become obvious." 
This book is soundly written, and ijiterspersed 
throoghout are historical references to some of the 
great clinicians of the past, many of whose names 
ai'e attache<l to present clinical entities. The book 
is concerned onlv with swellings and is well illus- 
trated with line drawings which bi-ing out the salient 
points. It does not cover the entire field of surgery 
and is not confined to the commoner conditions, but 
rather to those in which the diagnosis is be.st 
reached by clinical methods. It is a thoroughly 
practical and usable book in clinical practice. 

A TEXTBOOK OF BACTERIOLOGY. By Hans 
Zinsser, M.D.. Professor of Ba''teriologv and Im- 
munology. Harvard L'niversity Medical School; and 
Stanhope Bavne-Jones, M.D., Professor of Bacteri- 
ology, and Dean. Yale Univei'sitv School of Medi- 
cine. Eighth Edition. Revised and Reset. Price. $5. 
New York: D. Applcton-Century Company, Inc., 
1930. 

This book needs no introduction to the medical 
profession. It is intended for use by students of 
medic'ne and public health, and presents the funda- 
mentals of bacteriology and immunology and the 
apnlication of these to the undcstanding and con- 
trol of infer-tious diseases. Tn this edition the sec- 
tion on pathogenic protozoa has been omitted, and 
obsolete material has been removed. This results 
in some reduction in size of the book. The advances 



in bacteriology made within the last few years are 
well covered. References are listed at the end of 
each chapter, and the usual section on methods is 
present. 

TEXTBOOK OF NERVOUS DISEASES. By 

Robert Bing. Translated and enlarged by Webb 
Haymaker. Price $10. Pp. 838. St. Louis: The 
C. V. Mosby Company, 1939. 

The neurologist and the internist alike will find 
this excellent translation of the fifth German edition 
of Dr. Bing's work an indispensable addition to his 
medical library. This book, unlike most textbooks 
of neurolog.v, leaves the anatomy of the nervous 
system to other works, and concerns itself primarily 
with disease states of the brain, spinal cord and 
peripheral nerves. The book is clearly written, well 
translated, and well organized. The newer methods 
of treatment, including the use of thiamin chloride 
in the various conditions for which it is indicated 
are given full space. 

In Robert Waterbury's preface to the American 
edition, reference is made to the lucid style employed 
by Dr. Bing. The book does make interesting read- 
ing, and one is constantly impressed with the con- 
summate skill and accuracy of its famous author. 

The chapter on convulsive disorders contains an 
accurate appraisal of the relatively new drug, di- 
lantin, and explains its advantages over the time- 
honored bromides and phenobarbital. 

There is a good chapter on headache, and a eom- 
nlete discussion of the psychoneuroses. Complete 
bibliographies are furnished throughout the book. 
Altogether it is a worth-while book, and merits a 
wide sale. 

CLINICAL BIOCHEMISTRY. By Abraham Can- 
tarow. M.D., Associate Professor of IVIedicine, Jeffer- 
son Medical College. Biochemist. JetTerson Hosuital; 
and Max Trumper, Ph.D., Clinical Chemist and Toxi- 
cologist. formerly in chai-ge of the Laboratories of 
Biochemistry of the Jefferson Medical College and 
Hospital. Second Edition. Revised. Price. $5. 
Philadelphia: W. B. Saunders Company, 1939. 

This book has been thoroughly revised, and a 
number of new chapters and sections discuss- 
ing new topics have been added since the first 
edition. The book is designed to correlate labora- 
tory data with clinical findings in the field of 
biochemistry, thereby allowing the reader to select 
the appropriate tests valuable in diagnosis, and to 
interpret the data obtained from these tests in 
relation to the case at hand. In addition the book 
presents simply and accurately the fundamental 
principles of biochemistry as it is related to clinical 
medicine. The title has been changed from "Bio- 
chemistry in Internal Medicine" to "Clinical Bio- 
chemistry". A selected bibliography has been added 
at the end of each chapter, a marked improvement 
over the previous edition. At the end of the book 
there is an outline of clinical diagnostic features 
of various disorders, which is cross-indexed with the 
rest of the book. There is also a table of the nor- 
mal chemical standards of the blood and cerebro- 
sninal fluid, and of various chemical procedures. 
The book ought to be of distinct aid both in increas- 
ing the understanding of the biochemisti-y of the 
body, and in choosing and interpreting laboratory 
procedures. 



The Frontiers of Science. — In the year 1843 the 
Commissioner of Patents said in his report: "The 
advancement of the arts from year to year taxes our 
credulity and seems to presage the arrival o[ thai 
period when human improvement must end." — Win- 
fred Overholser: The Broadening Horizons of Medi- 
cine, Science, 90:2338 (Oct. 20) 1939. 



February, 1940 



ADVERTISEMENTS 



in 



L_ 



STUBIES IM THE A VITAML¥OSES 




This page is the second of a series on vitamin deficiencies presented 
by the research division of The Upjohn Company because of the 
profession's widespread interest in the subject. A tv^ro-page insert 
on the same subject appears in the February 17 issue of The 
Journal of the American Medical Association. 



Manifestations of Vitamin A Deficiency 



One of the early manifestations of vitamin A 
deficiency is nyctalopia, a loss of visual acuity 
in dim Hght. While several pathologic states 
(retinitis pigmentosa, toxic amblyopia, de- 
tachment of the retina) also produce night 
blindness, vitamin A deficiency is probably 
the most frequent cause. After exposure to 
the bUnding glare of a bright Hght the nor- 
mal eye adapts itself relatively quickly to 
lowered illumination. In nyctalopia due to 
vitamin A deficiency, the time 
required for recovery of visual 
acuity is longer. 

In otherwise normal eyes, 
measurement of capacity for 
dark adaptation by means of the 
biophotometer has been sugges- 
ted as a method of discovering 
vitamin A deficiency. 












^ 


=^ 


^ 




^ 






-~~ 








I-- 


^^ 






A 


^ 




y 












-<^ 








\ N 


/ 


/ 






















\ 


/ 


/ 






















\ 


/ 
























\ 


/ 
























\ 


/ 
























\ 


/ 


























/ 
















— 






— 

















Lower line shows 
the longer lime re- 
quired for the 
recovery I o pre- 
exposure level by 
the nyctalopic. 







*T«t>L»;i 



Above, atratiiied, keralinizing epi- ^ fk*! 
thelium o( the turbinate mucous - - 

membrane ol a vitamin A deficient 
monkey; at right, normal mucosa. I 




Pathologic epithelial changes produced by vitamin A 
deficiency are illustrated by the photomicrographs of 
turbinate mucous membrane taken from normal and vita- 
min A deficient monkeys. The progressive pathologic 
process consists of atrophy of 
the epithelium, reparative 
proliferation of the basal cells 
and finally, as depicted in the 
upper photograph, replace- 
ment of the normal by a strati- 
fied, keratiniz- ^'/3%. 
ing epithelium. y-fr^^ 
lUPJOHNl 




•2i . v^ >"•"• V» ••»«'. 



IV 



CONTENTS 



February, 1940 



North Carolina Medical Journal 

Official Organ of 
The Medical Society of the State of North Carolina 



Volume l 

Number 2 



February, 1940 



$8.00 A YEAR 

80 CENTS A COPV 



CONTENTS 



Original Articles 

The Making of a Clinician — David Riesman, M.D. 65 

Vaginal Ureterolithotomy— Donnell Cobb, M.D. 70 

A Case of Ainhum Treated by Lumbar Sympa- 
thetic Ganglionectomy — R. B. TUcKnight, M.D. 76 

Cod Liver Oil Treatment of Burns and Wounds 
Parker C. Hardin, M.D. - - 82 

Malaria Studies and Investigations in North 
Carolina — C. M. White. Engineer, and L. L. 
Parks, M.D. - - - - - 92 

Low Back Pain and Sciatica With Special Ref- 
erence to Rupture of the Intervertebral Disk 
— Barnes Woodhall, M.D., R. Beverley Raney, 
M.D., and W. W. Vaughan, M.D. - - - - 94 

The Relationship of Gynecology and Urology — 
Edgar V. Benbow, M.D. - - 101 

Present Dav Diagnosis and Treatment of 
Chancroidal Infection — Walter L. Thomas. 
M.D. 104 

The Role of Pectin in Diarrhea— G. W. Kut- 
scher, M.D. - - - - 107 

Editorials 

"The Scarcity of Doctors" ------- 109 

A Modern Classic ---------- 110 

Spool Cotton as a Suture Material - - - - 110 
A Message to the Medical Society of the State 
of North Carolina from the Auxiliary Through 

its President -- HI 

The Woman's Auxiliary -------- 111 

Casi, Kepokis 

Tularemia: Report of a Case of the Oculo- 
Glandular Type— B. W. Fassett, M.D., Durham 112 

A Note on Neuralgias of Cranial Nerves — 
Frederic M. Hanes. M.D. - - 113 

Clinico-Pathologioal Conference, City Memorial 
Hospital - - - - . . - m 



The Bulletin Board 

Notes from the Office of the Secretary-Treas- 
urer - 115 

American Board of Obstetrics and Gynecology 
Examinations -----------115 

South Atlantic As-sociation of Obstetricians and 
Gynecologists ------ 115 

American Academy of Pediatrics 115 

Bowman Gray School of Medicine of Wake 
Forest College ---------- 116 

News Note from Duke University School of 
Medicine -------------ll'» 

Notes froni the Division of Public Health of 
University of North Carolina 116 

State Board of Charities and Public Welfare - 117 

Southeastern Surgical Congress 117 

North Carolina Neuro-Psychiatric Society - - 118 

State-Wide Syphilis Survey 118 

County Societies - - - - 119 

News Notes -119 

Resolution Adopted by the National Association 
of Retail Druggi.sts ---------119 

Woman's Auxiliary 

Officers ------- 120 

An Appeal to the Doctors from the Auxiliary 120 
Minutes of the Semi-Annual Meeting of the 

Board of Directors --------- 120 

In M E.MORI am 

Page 122 

Book Reviews 

Page 123 



Application for entry as second-class matter at tlie Post Office in WIn.ston-Salem Is pendinff. Copyright 1940 by the Medical 

Society of the State of North Carolina. 



North Carolina Medical Journal 

Owned and Published By 
The Medical Society of the State of North Carolina 



Vol. 1 



February, 1940 



No. 2 



THE MAKING OF A CLINICIAN 

David Riesman, M.D. 
Philadelphia 



Three things that had their roots in the 
nineteenth and their development in the 
present century have radically altered the 
course of medicine — the invention of instru- 
ments of precision, the development of bio- 
chemistry, and the rise of specialism. 

Instruments of precision, among which I 
include the x-ray, have oriented medicine 
and science as a whole in the direction of 
quantity or measurement. Instruments of 
precision are nice and neat and precise. So 
seemingly are the data derived from them. 
They satisfy the human longing for cer- 
tainty, but they can never give a complete 
insight into the human mind, or even into 
the human body as a whole. 

Biochemistry is likewise a quantitative 
science. Nothing has contributed more to 
our understanding of human physiology in 
health and in disease than the work of the 
chemist and the biologist. 

In addition to such invaluable fundamen- 
tal knowledge, these two sciences have placed 
in our hands new remedies of enormous 
actual and potential value. I need only men- 
tion antitoxins, salvai-san (arsphenamine) , 
insulin, liver extract and sulfanilamide. 

The revelations of electric brain waves ,a 
science as yet in its infancy, may throw 
much light on heredity, on human person- 
ality and other subtle phenomena of life. 
But when all these discoveries present and 
to come are added together, something still 
remains that will elude quantitative measure- 
ment — the emotions, thought and the psyche. 
Since we learn about them only by psy- 
chiatric and psychoanalytic means and since 
their importance cannot be overestimated, 
their study must be incorporated in our 

Address delivered at the dedicntion of the new Medical nml 
Public Health Building of the University of North Carolina 
at the Sesqui-Centennial Celebration on December 4. 1939. 



teaching and our practice. I am glad to see 
increasing evidence of a distinctly psychoso- 
matic outlook. 

Of all the factors influencing the develop- 
ment of medicine specialisms has brought 
about the greatest change since I entered 
the profession. A famous surgeon like D. 
Hayes Agnew of Philadelphia, who, it will 
be remembered, was called to attend Presi- 
dent Garfield after he was shot, took out 
cataracts from the eyes and stones from the 
bladder with equal skill. Only an occasional 
opthalmologist limited himself to his special- 
ty. Even I in my humble way did many 
things that I later abandoned — obstetrics, 
minor surgery, nose and throat treatment 
and simple gynecologic procedui-es. 

The public has become so specialist-con- 
scious that many persons without consulting 
their family physician go directly to the 
cardiologist, the allergist, the metabolist or 
the gastroenterologist for advice. Some have 
even added a "gland specialist" to their ever 
lengthening list. Bliss Perry<" exaggerates, 
however, when in speaking of specialists, he 
says: "Of course their advice was sound, 
and most of it, except the cardiograph's, is 
to be found in Cicero's 'De Senectute' ". 

I do not want to give the impression that 
the rise of specialism is an evil. Concentra- 
tion upon a single field increases one's skill 
in that field, but it has inevitably the tend- 
ency to narrow one's outlook. A specialist 
is in danger of considering his branch of 
disproportionate importance; he comes to 
live in a water-tight compartment. 

On the other hand the clinician with 
whose making I am concerned is not a nar- 
row specialist. He is first of all an internist 

(1.) Perry, Bliss: And Gladly Teach, Boston, 1935, 
p. 264. ' 



66 



NORTH CAROLINA MEDICAL JOURNAL 



Februarv, 1940 



— that is. he ileals with the diseases of all 
the internal organs including the nervous 
system. In addition he is a teacher at the 
bedside, for that is what the word clinician 
means. It is derived from the Greek word 
Mine, "a bed". In other words the clinician 
is a practitioner and teacher of internal 
medicine. 

Usually a clinician is also an authority in 
one of the special fields of medicine, but he 
will not confine his interests or teaching to 
that field, nor will he desire that the public 
or the medical profession shall consider his 
interests limited to it; by his writings he 
will show that his fielcl covers a wider range. 

Clinical medicine of this type which takes 
almost the whole body for its domain began 
about two hundred years ago in the little 
university town of Leyden in Holland. Here 
a round-headed, full-moonfaced Dutch phy- 
sician. Hermann Boerhaave. took medical 
students into the wards of his small hospital 
and taught diagnosis and treatment at the 
bedside. So successful was he that students 
flocked to him from all parts of the world, 
including America. The great Albrecht von 
Haller called him "totius Europae magister" 
— the teacher of all Europe. 

Boerhaave's example made its way very 
slowly among the medical faculties in 
Europe. The tradition of teaching from old 
texts was too strong. Edinburgh, founded 
by pupils of Boerhaave. was one of the first 
universities where bedside teaching was 
practiced. As the first medical school in 
the American Colonies — the University of 
Pennsylvania — was founded by graduates of 
the Athens of the North, it is not surprising 
that clinical teaching found an early home 
in Philadelphia. Thomas Bond began to give 
bedside instruction in the Pennsylvania Hos- 
pital in 1766. The next clinical professor 
in this country was James Jackson of the 
Harvard ^ledical School, who was elected in 
1821 and gave his lectures at the newly 
opened Massachusetts General Hospital. 
Jackson is famous in his own right and also 
by reason of his brilliant son, James Jack- 
son, Jr., the favorite pupil of the great 
French teacher, A. P. C. Louis. 

Although the University of Edinburgh had 
lectures in clinical medicine in the 18th cen- 
tury it had no professorship in that subject 
until 1913. 

In Germany the title of clinical profes.sor 
as distinct from that of professor ' of the 



theory and practice of medicine does not 
exist ; every professor of medicine is ipso 
facto a KUniker, or clinician. 

In this country the example of Thomas 
Bond and James Jackson had very few imi- 
tators in the first half of the 19th century. 
In the great majority of medical schools 
teaching was entirely by lectures*. Of thirty- 
seven medical colleges in 1851, clinical or 
bedside instruction, always meager, was 
available in only sixteen. 

I was fortunate in arriving on the medical 
scene at a time when a wonderful group of 
men who represented clinical medicine at its 
best flourished in this country. They en- 
compassed the whole realm of internal medi- 
cine and were helpful advisors in diseases 
of all the internal organs. They were gen- 
eral consultants: I might say national con- 
sultants. Like the Michelangelos and the 
DaVincis of the Renaissance, these physici- 
ans were versatile men. These I have in 
mind — Reginald Fitz. Edward G. Janeway, 
J. M. DaCosta. William Pepper. William 
Osier. Frank Billings and John H. Musser 
— occupy permanent places in the medical 
pantheon. Fitz, Janeway and DaCosta were 
past their prime when I began the practice 
of medicine, but the echo of their great work 
was still audible in my youth. 

Reginald Fitz made his name immortal by 
his fundamental studies on perforation of 
the appendix, a condition well-known today 
but poorly understood before Fitz's time. 
We also owe to Fitz pioneer investigations 

•I was interested to find that in Trinity Collepre 
Medical School. Dublin, in the early years of the 
nineteenth century, there had been clinical profes- 
."iors. holding, however, subordinate rank. 

When Professor James Macartney proposed in 
1,S14 that before students pre.«ented themselves for 
their final examination, they should have a practi- 
cal test in English, his proposal was bitterly op- 
posed by the other professors who in.'iisted that not 
only should all examinations practical as well as 
theoretical be conducted in Latin but that the clini- 
cal lectures and the reports of cases studied should 
also be in Latin. 

One of the professors, named Hill, expressed him- 
self as follows: "Examinations in English as in- 
troductory to a learned profession are so absolutely 
contrary to the conception which I entertain of a 
literary education, as to render it impossible that 
I would tolerate them in any case in which I 
possessed any influence. No instance of the kind 
has ever happened to me. and in the examinations 
of Medical Candidates under a Liceat ad exami- 
nandum how could I in any possibility be satisfied 
through such examination of the Candidates beinjr 
Doctrina idoneum." (Kirkoatrick. T. Percy C: His- 
torv of the Jledical School- and Trinity College, 
Dublin, Dublin, 1912. p. 235.) 



February, 1940 



MAKING A CLINICIAN— RIESMAN 



67 



on acute pancreatitis, his paper on that sub- 
ject being a medical classic. 

Edward G. Janeway had been a patholo- 
gist and a teacher of pathology in his early 
years. It was this training undoubtedly that 
made it possible for him to become one of 
the leading medical consultants of his time. 
Janeway 's son .seemed destined to rival his 
father, but pneumonia carried him off in the 
prime of life. 

J. M. DaCosta's text-book on medical diag- 
nosis was one of the first works in this 
country on that subject. It passed through 
many editions. DaCosta had a remarkably 
keen ear. Dr. Deaver once told me that at 
a consultation DaCosta, after examining the 
patient, turned to the other doctors present 
and .said in all seriousness that he had heard 
"the echo of a rale". DaCosta was famed 
throughout the country as one of the great- 
est clinical lecturers in American medical 
hi.stoiy. 

William Pepper, a brilliant teacher, always 
began his lectures almost with the very word 
that would naturally have followed where he 
had left off in the preceding lecture. If the 
first sentence in a new lecture and the la.st 
in the old had been placed together, not even 
a paragraph would have separated them. I 
am reminded of Luis de Leon, who, when he 
returned after five years in the prison of 
the Inquisition, began his lecture to his stu- 
dents of the University of Salamanca, "As 
we remarked when we last met".'-' 

William Pepper, like Janeway and Fitz, 
began his career as a pathologist. It was 
he who discovered that in pernicious anemia 
the yellow bone marrow becomes red, a dis- 
covery that a year later was made inde- 
pendently by Julius Cohnheim in Germany, 
who usually gets the credit for the observa- 
tion. It is also probable that Pepper saw 
the malarial parasite several years before 
Laveran. 

William Osier is the ideal of all Americans 
who aim to be clinicians. He resembled 
Boerhaave in that he was the one who es- 
tablished for the first time complete bedside 
teaching in this country at Johns Hopkins 
Hospital. Like Boerhaave he attracted 
pupils from everywhere. Osier was jiroud 
of his pioneer work and wanted as his only 
epitai)h, "I taught medical students in the 
wards." 

(2.) Howe. M. A. de Wolfe: Holmes of the Break- 
fast Table, London and New York, 1939, p. 32. 



Thoroughly at home in pathology — a good 
deal of his training in this field was obtained 
at the Philadelphia General Hospital — , fa- 
miliar with medical literature to a degree 
rarely equaled. Osier became one of the 
greatest clinicians of all time. In achiev- 
ing this distinction he was helped by another 
accomplishment — a profound knowledge of 
medical history and of general literature, 
which is evident in all his writings and gives 
them their peculiar and perennial charm. 

Osier always emphasized the importance 
and value of careful physical examination. 
More mistakes, he believed, were due to 
omission than to commission, to overlooking 
than to faulty reasoning. 

John H. Musser was one of my teachers, 
and also a friend of my medical youth. A 
good pathologist and a real expert in physi- 
cal diagnosis, he had an unusual flair for 
guessing correctly. His private and consult- 
ing practice was enormous, so exacting that 
it killed him at the early age of fifty-six. 
His textbook on diagnosis and his volumi- 
nous writings show the breadth of his 
knowledge of medicine. 

Frank Billings of Chicago, large of frame 
and big of brain, in some respects the Daniel 
Drake of his time, was a keen, independent 
clinician whose mastery of medicine in its 
principal phases made him an admired 
teacher and a much sought after consultant. 
To these qualities he added the gift of stimu- 
lating research in others. We owe to him 
and his pupils the modern ideas of focal in- 
fection. 

I cannot refrain from telling a story of 
Billings : He was once called as an expert 
witness, had given his testimony and had 
been turned over to the opposing attorney. 
This man began, "You are Dr. Frank Bil- 
lings?" "Yes." "You are the great Dr. Bil- 
lings?" "I am Dr. Billings." "People come 
to you from the country over?" Dr. Billings 
smiled. "You are the Doctor Billings that 
is called in on all important serious cases?" 
Dr. Billings' face expanded more and more 
and he smiled benignantly. "You are called 
practically always when some important citi- 
zen in this community is ill?" Dr. Billings 
admitted this. "You were called when Mr. 
Lawrence was ill?" "Yes sir." "Mr. Law- 
rence died." "Yes sir." "You were called 
when Mr. William Fairbanks was ill?" "Yes 
sir." "He died?" "Yes sir." "You were 
called clear across the country when Mr. 



68 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



Marshall Field was ill?" "Yes sir." "Mr. 
Field died?" "Yes sir." "You were called 
in when Mr. Harrison was very ill?" "Yes 
sir." "He died?" "Yes sir." "That will 
do, Dr. Billings." 

Dr. Billings stepped off the witness stand 
completely flattened and hoped that he might 
some time meet that rascally la^\•J•er in a 
dark alley at night. 

Germany before the war also had a lai-ge 
number of truly great clinicians — Kraus. 
Ewald. Senator and His in Berlin, von Muller 
in Munich, and others in the smaller univer- 
sities. I might add parenthetically that near- 
ly all the great men in the larger German 
cities were taken from the smaller universi- 
ties where their abilities had been tested 
over a period of years. That system of pro- 
gressive movement from smaller to larger 
fields had done much to make pre-war Ger- 
many the principal center of medical science 
in the world. In this country we have per- 
haps been given too much to inbreeding. 
There is a curious resistance, especially 
among alumni groups, to the calling of men 
from the outside. 

The clinicians whose biographies I have 
briefly given were all-round physicians and 
teachers because they were masters of phy- 
sicial diagnosis and were skilled pathologists. 
The reason they have had only few succes- 
sors is that the present generation more and 
more neglects those two foundation stones 
of clinical medicine. To illustrate I shall 
quote from the Harvey Oration delivered in 
1930 by a distinguished English physician, 
G. Lovell Gulland'^': "The time will come 
when the differential count will be more im- 
portant than the auscultation of the heart." 
This remarkable statement is a clear pres- 
entation of a trend of modern medicine that 
I believe to be unwholesome and unwise. 

One might ask Dr. Gulland, "If you were 
ill, would you prefer to be ti-eated by a man 
who knew all about the differential count 
and little about auscultation of the heart, or 
vice versa?" There can hardly be any doubt 
what the answer would be. But. I shall not 
pursue that orgumevtum ad hominem. 

I am, however, deeply concerned over the 
growing tendency to magnify the laboratory 
at the expen.se of the bedside study of dis- 
ease. Not that I am unaware of the pos- 
sible charge that it is a failing of old men 

(3.) Gulland, G. L.: The Circulating Fluid, Edin- 
burgh M. J., .37:567, 1930. 



to talk of the great personages of their day, 
to say that nothing is as good as it was. It 
is only too easy, I know, to be laudator tem- 
poris aeti. But are not the young equally 
under a delusion when they think that no- 
bodv is anv good who was not born vester- 
day? 

I do not want to convey the impression 
that I lack respect for the laboratory. No 
one can value more than I do the help it 
gives in diagnosis and treatment, and in ad- 
vancing the science of medicine. As a place 
for research it offers the greatest hope for 
the future welfare of mankind: but as a 
practicing physician I cannot approve of 
the growing habit of thrusting the burden 
of diagnosis upon the laboratory, when we 
might arrive at a diagnosis ourselves by the 
simple expedients of a good history and a 
careful physical examination. 

More than one intern has come under my 
observations who. when I asked him "What 
do you think ails this patient?" replied, "I 
have ordered the laboratory work, but the 
reports have not come through yet." That 
is the wrong approach. The hospital or 
medical school that turns out men who at- 
tack the problem of disease in that fashion 
fails in its duty. How often are we as 
physicians obliged to make a diagnosis on 
the spot. In consultation practice the con- 
sultant nearly always has to arrive at a 
decision before he leaves the patient's house. 

Another reason for the rarity of the older 
type of clinician is the loss of interest in 
pathologj', in morbid anatomy. Evei-y one 
of the great men of whom I have spoken \vas 
a good pathologist and knew the appearance 
of diseased organs and the physical signs 
and sj-mptoms they produced during life. 
DaCosta long ago said the best portal of 
entry into clinical medicine is pathologj". 

During my early years as pathologist the 
autopsy room would be filled with interns 
and young doctors whenever a postmortem 
was being held. Recently I attended an 
autopsy in one of our largest hospitals. 
There was only one intern present: yet the 
ea.se was an interesting one, capable of teach- 
ing important lessons. 

I have thought about the possible rea.sons 
for the lack of interest in autopsies and have 
come to these conclusions: The autopsies 
today are made by men who are purely 
pathologists and know little or nothing about 
clinical medicine. They cannot therefore 



Februai-y. 1940 



MAKING A CLINICIAN— RIESMAN 



69 



correlate the findings of the postmortem 
with the symptoms and signs during life. 
It was the ability of the earlier pathologists 
to do this that caused autopsies to be so well 
attended. This probably unalterable situa- 
tion can be overcome if the physician — • 
senior or junior — who saw the patient dur- 
ing life is present at the autopsy. 

During recent years I have adopted a 
method of teaching clinical medicine with 
the definite purpose of giving to my students 
a greater independence and self-reliance. 
This method is as follows : 

During ward rounds I take a new case 
about which I know nothing — often one re- 
cently admitted. Beginning at the begin- 
ning, I ascertain the history, limiting my 
questions to essentials. Then I make the 
physical examination, questioning the stu- 
dents as I proceed as to what I am endeavor- 
ing to ascertain in the light of the history ; 
all unnecessary examinations are omitted. 
In the process of examination I refrain from 
asking the results of x-ray or other labora- 
tory studies, but try, with the help of the 
students and the interns, to arrive at a 
diagnosis. The whole procedure aims to 
represent the process the physician or con- 
sultant has to go through when he sees a 
private patient for the first time. If a 
diagnosis cannot be made on the basis of 
the history and physical examination, then 
I inquire as to such laboratory data as seem 
to be necessary, and if the tests have not 
been made I order them. 

By this approach I try to counteract 
among my students the growing habit of 
putting the patient, as it were, into a labora- 
tory hopper and having him come out fully 
diagnosed with a minimum amount of cere- 
bral activity on the part of the student and 
intern. 

It has always seemed to me that for the 
practical training of students in clinical 
medicine the out-patient department is bet- 
ter than the wards of a hospital. Dispen- 
sary practice is akin to private practice. The 
time for study is brief, the tools are limited, 
the diagnosis has to be made on the spot. 
Where the instructor in charge is consci- 
entious, practice among out-patients unques- 
tionably sharpens the .student's clinical sense, 
makes him a better observer, a keener and 
quicker reasoner, altogether a more inde- 
pendent human being. I should like to see 



dispensary instruction placed in the fourth 
year of the medical curriculum. 

The ideal clinician of the future as I see 
him in my mind's eye will be a greater man 
than the Osiers of the generation before me. 
He will naturally be at home in physiology 
and in biochemistry. He will utilize the data 
of the specialist understandingly, not blind- 
ly, and he will be a capable psychologist. 
Having these qualities, he will be able to 
inspire students as he stands at the bedside 
of the patient. He will probably do some 
research work, especially in the wards and 
out-patient department, and will stimulate 
laboratory research suggested by his bedside 
experience. 

He will have to pay for this comprehen- 
sive knowledge by giving more time to his 
preparation, more time to keeping up with 
medical progress. This race of medical 
supermen — will they find any leisure for the 
humanities? For the humanities .should not 
be left out of a doctor's life. I believe it is 
possible for a man to cultivate the humani- 
ties as his avocation. While the height of 
the body is limited, the extent of the mind 
is not. You can fill the memory, but it never 
runs over. 

Medicine is advancing so rapidly, the 
literature is piling up with such disturbing 
speed, that only by intense application can 
a medical man keep in step with medical 
progress. However, it is possible if he can 
create for himself in the very beginning a 
pattern of work — "for the gods bring 
threads to a web begun." (" 

(4.) Hale, George Ellery, quoted in Isis, 236, May, 
1939. 



A Doctor of the Old School. — The physician who 
cared for me during my childhood was a genius' of 
his day. Let us not raise the question of whether 
he served society by helping me to live through the 
gamut of infectious diseases, then highly lethal, but 
now mostly under scientific control. That physician 
was almost self-educated. He read, rode, and 
practiced under guidance of his predecessor of a 
still earlier generation. Whether his patients lived 
or died, he studied the results to guide him in sub- 
sequent cases. That doctor's fees' were moderate 
though paid with difficulty and gratitude — some- 
times paid mostly in gratitude. His house was the 
best in the whole community, his riding and driving 
horses the best, his" advice and leadership gladly 
accepted by nearly all citizens. His occasional de- 
feats by John Barleycorn were promptly forgiven by 
all except the preachers, who also forgave him 
when their next illness came upon them. — Caldwell, 
Otis W.; Some Problems of an Educated Minority, 
Science 89: 2322 (June 30) 1939. 



70 



NORTH CAROLINA MEDICAL JOURNAL 



February. 1940 



VAGINAL URETEROLITHOTOMY 

With a Review of Reported Cases 

DONNELL B. Cobb, M.D., M.S., F.A.C.S. 

GOLDSBORO 

Each case of ureteral calculus requires in- 
dividual solution. Factors influencing the 
type of treatment are: the size and location 
of the stone, its progress down the ureter, 
the degree of obstruction produced, the se- 
verity of any co-existing infection, and the 
intensity of the patient's suffering. The 
proper treatment of a ureteral stone fre- 
quently requires more careful judgment tlian 
is usually exercised in handling otner lesions 
of equally common occurrence, if tlie kianey 
is to be conserved and undue and prolonged 
suftering prevented. 

It is generally conceded that about 50 per 
cent of ureteral stones will pass without In- 
strumental or operative intervention. Lead- 
ing urologists dirt'er greatly in reporting the 
percentage they are able to remove by cysto- 
scopic manipulation. 

Of the stones that do not pass spontane- 
ously, or that cannot be made to pass by the 
use of the cystoscope, the greater number 
become lodged in the lower third of the 
ureter. This is especially true in women. 
Young >' , in 1903, emphasized, that "tnat 
portion of the ureter lying within the broad 
Mgament is frequently narrowed by disease 
of the female pelvic organs, and furnishes a 
common point for the impaction of calculi." 
Beer'-' found it advisable to operate on 
34 per cent of patients with stones in the 
lower ureter. \'on Lichtenberg^^' operated 
on 30 per cent of these patients, and has 
said that he "would much rather do the 
operation early in a certain percentage of 
cases, feeling that the kidney is spared by 
a careful operation far more than if a long 
drawn-out, conservative plan of procedure is 
adopted; although such a procedure may be 
successful in getting the stone, the kidney 
goes onto partial destruction." 

The keen satisfaction that is experienced 



Kead before the Section on Surgen'. Medical Society of the 
State of Nurth Carolina, Bermuda Cruise, May IS, 1939. 

1. Young, H. H.: The Surgery of the Lower 
Ureter, Ann. Surg. 27:668, 1903. 

2. Beer, E. S.: Diagnosis and Treatment of Ure- 
teral Calculus, New York State J. Med. 16:501, 
1916. 

3. von Lichtenberg, A.: HamJeiterstcin-Erkran- 
kung, Jahresk, f. arztl., Fortbild. 20:30, 1929. 



by the cystoscopist in extracting a stone 
from the ureteral orifice is a strong stimu- 
lant to treat the next case in the same way. 
And yet, at times, patients who have had 
multiple manipulations and dilatations come 
to fear the procedure more than an opera- 
tion. One should be careful that one does 
not, for tne sake of statistics, prolong sucn 
treatment beyond the point of safety. 

Stones that are not made to pass after two 
or three cjstoscopic manipulations are usual- 
ly found to be embedded in the ureteral wall, 
or densely adherent to it. The duration and 
severity of tne impaciion, and not tne size oi 
the stone, should determine the decision to 
operate. Bumpus^^ has pointed out that 
prolonged intra-ureteral manipulation may 
lead to an acute-supperative nephritis. He 
reports two sucn aeatns; ^Uunger^ recoras 
one; and I have seen one. 

The extreme difficulty that may be ex- 
perienced in removing a stone from the 
lower ureter by the usual methods of ap- 
proach is undoubtedly one reason why pro- 
longed and repeated cystoscopic trials meet 
with almost universal approval. The extra- 
peritoneal incisions advocated by Gibson in 
1910, and by Judd"* , in 1914, permit a 
most satisfactory e.xposure of the ureter; 
but in order to follow it to the bladder and 
remove a stone located in the extreme lower 
portion, it sometimes becomes necessary to 
divide the round ligament, the broad liga- 
ment, and the uterine artery. It is stones 
within this "area of difficulty" and present- 
ing such surgical hazards when handled by 
the usual methods of approach that lend 
themselves so readily to an approach from 
below through the vagina. And yet, most 
surgeons have been reluctant to take ad- 
vantage of nature's provision and to remove 
through the vagina a stone that hes immedi- 
ately beneath the finger on vaginal palpa- 
tion. 

It is true that vaginal ureterolithotomy 
has not been mentioned often enough in the 
medical literature to keep us aware of its 
possibilities. A thorough review of the litera- 

4. Bumpus, H. C, and Thompson, G. J.: Stones 
in the Ureter, Surg. G.vnec. & Obst. 50:106 
(Feb.) 1930. 

5. Hunger, A. D.: Management of Calculi in the 
Lower Third of the Ureter, A.n. J. hurg., 
39:584-588, 1938. 

6. Judd, E. S.: A Method of Exposing the Lower 

End of the Ureter, Ann. Surg. 59:393, 1914. 



February, 1940 



VAGINAL URETEROLITHOTOMY— COBB 



71 



fure reveals only 74 reported cases. We have 
(lone six such operation, four of which have 
been previously reported <", thus making a 
total of 80. It is upon a study of these 80 
cases that this paper is based. When the 
close relation of the lower ureter to the 
anterolateral vaginal wall is considered, it 
seems strange that this method of approach 
is so seldom used. 

Because of the difficulty in removing a 
stone from the extreme lower ureter, numer- 
ous operative procedures have been devised 
and carried out. Ceci, in 1867, removed a 
ureteral stone through an incision in the 
rectum. The patient died 26 hours later. 
The repoi't of this case led to repeated con- 
demnations of this method, and no one since 
has used it. In 1892, Cabot'"' used the 
Kraske incision, removing the coccy and 
lower part of the sacrum with division of 
the sacroiliac ligament. He performed this 
operation successfully, as did Ferria, but he 
called attention to the difficulty in securing 
adequate exposure, and to the danger of 
hemorrhage from the hemorrhoidal vessels. 
The severity of the procedure caused its 
abandonment. Writing in 1898, Fenwick*"' 
reported the use of a prerectal or transverse 
perineal incision, separating the rectum 
from the bladder. Regnier also tried this 
method but failed. In the same year the 
statement was made "that stones impacted 
in the pelvic portion of the ureter were in- 
accessible to surgical treatment." Neverthe- 
less, Rigby<"'>, in 1907, advocated an equally 
difficult and unsatisfactory procedure. He 
advised a parasacral or pararectal incision, 
differing from Cobot's operation only in that 
the coccyx and sacrum were not disturbed. 
He reported four cases, but his method failed 
to gain popularity. Kelly, in 1914, <"' de- 
vised the transvesical approach to ureteral 
stones lodged adjacent to the bladder, using 
a vesico-vaginal incision. 

7. Cobb, D. B.: Vaginal Ureteroli'.hotomy, South. 
Surg. 1:230-241, 1932. 

8. Cabot, A. T. : Observations upon the Anatomy 
and Surgery of the Ureter, Am. J. M. Sc. 103: 
43, 1892. 

9. Fen wick, E. H.: Operative Treatment of Cal- 
culi which have Been Lodged for Long Periods 
in I^wer Uretei-, Edinburg M. .1. n.s. 3:281, 
1898. 

10. Rigby, H. M.: Operative Treatment of Cal- 
culi Impacted in Pelvic Portion of Ureter, Ann. 
Surg. 46:793, 1907. 

11. Kelly, H. A.: Diseases of the Kidneys, Ureters 
and Bladder, New York, D. Applcton and Co., 
1914, vol. 2, 159-163. 



Emmett(i2), of New York, in 1884, was 
the first to give an account of the removal 
of a lower ureteral stone through the vagina. 
Higgins'") of the Cleveland Clinic, in 1937, 
reported eleven cases, the largest number 
recorded by any one author. 

In the female the ureter runs forward and 
inward beneath the broad ligament, passing 
beneath the uterine vessels and lying about 
2 cm. from the side of the uterus, at the 
level of the internal os. Emerging from the 
anterior surface of the broad ligament, be- 
fore entering the bladder, it passes obliquely 
across the anterolateral vaginal wall, with 
which it is in direct contact. During this 
part of its course it is not covered with 
peritoneum but is loosely supported by con- 
nective tissue. 

It has been stated that 90 per cent of nor- 
mal ureters can be palpated through the 
vagina. After assiduously attempting to ac- 
quire this art for a number of years, I am 
forced to the conclusion that vaginal palpa- 
tion of a ureter is posible only when some 
abnormality exists. The presence of a cathe- 
ter in the lower ureter makes it ea.sy to trace 
its course. When the ureter is the seat of 
inflammation or tuberculous infiltration, it 
is readily palpable. Stones situated within 
the ureter at any point between the base of 
the broad ligament and the bladder are 
readily felt through the vagina. Here it is 
interesting to note that Pauley"*' reports 
five cases and Igron"'' four cases in which 
they were able to remove stones from the 
lower ureter simply by bimanual manipula- 
tion, having one hand on the lower abdomen 
and the other in the vagina milking the 
stone down. They advise trying this ma- 
neuver before attempting any other pro- 
cedure. 

The various operators writing on vaginal 
urterolithotomy describe two methods of ap- 
proaching the ureter through the vagina. 

One method, as described by Doyen,""' 
consists of incising the anterior culdesac, as 

12. Emmet. T. A.: Principles and Practice of 
Gynecology, Philadelphia, Henry C. L*a's Son 
& Co., 1884, ed. 3, p. 796. 

13. Higgins, C. C: Vaginal Ureterolithotomy; 11 
cases, Urol. & Cutan. Rev. 41:609-612, 1937. 

14. Pauley, V. L.: The Removal of Ureteral Cal- 
culi by the Aid of Bimanual Vaginal Manipu- 
lation, Urol. & Cutan. Rev., 38:201-204, 1934. 

1.5. Igron, S. M.: Transvaginal Route in Uretero- 
lithotomy, Khirurgiya, no. 1, pp. 133-136, 1937. 

10. Doyen: Calculs des Ureteres, Courrier med. 
185, 1897. 



72 



NORTH CAROLINA MEDICAL JOURNAL 



February. 1040 



in vaginal hysterectomy, separating the blad- 
der from the uterus as high as the vesico- 
uterine fold of peritoneum and exposing the 
ureter by gauze sponge and finger dissection. 
Furniss"" recommends this type of ap- 
proach to the ureter, and, if the vagina is 
small, advocates making an incision in either 
one or both vaginal sulci, high in the vagina 
and extending through the transversus pe- 
rinei and levator ani muscles. 

The method used by the greatest number 
of authors and the one employed by us, is 
to make a simple incision through the antero- 
lateral vaginal wall in the line of the ureter 
— the stone acting as a guide — expose the 
ureter, and remove the impacted calculus. 

Technique: The patient is placed in the 
lithotomy position and the vagina is exposed 
with a weighted speculum over the perineum 
and retractors against the lateral walls. The 
cervix is grasped with a tenaculum and 
pulled downward and to the opposite side, 
thus drawing the base of the bladder and 
the lower ureter near the introitus. After 
the stone is felt an incision is made through 
the anterolateral vaginal wall in the line of 
the ureter. The index finger is passed 
through this incision .so as to locate the stone 
and ureter; then a blunt hook or AUis for- 
ceps is passed around the ureter above the 
stone. This prevents the stone from slipping 
up and out of reach. By gentle traction on 
this hpok or forceps and by simultaneously 
releasing the pull on the cervix, the ureter 
containing the stone is brought through the 
vaginal incision. The stone is then removed 
through a longitudinal opening in the ureter. 
The ureteral incision is closed with two or 
three interrupted absorbable sutures passed 
through its outer layers, a rubber tissue 
drain is placed down to the ureter and 
brought out at the lower end of the vaginal 
incision, which is closed with a continuous 
suture. 

Singleton*'"' and Morris*"" have advised 
the passage of a catheter up the ureter 
before operation so as to aid in its identifi- 
cation. Shaw expresses the opinion that the 
passage of such a catheter will also serve to 
fix the stone in its location and make it less 

17 Furniss, H. D.: VaKinal Ureterolithotomy, Am. 
J. Sm-R. 17:249-253, (Aug.) 1932. 

18 Singleton. A. O.: Kiflnev and Ureteral Calculi, 
Texas State J. Med. 17:486, 1922. 

19 Morris, Henry: Surjiical Diseases of Kidney 
and Ureter, Chicago, W. T. Keener, 1903, vol. 
2, 529-530. 



liable to slip up the ureter and out of reach. 
We have done this, but do not believe it 
necessary. A stone that is easily palpable 
will serve as an efficient guide in locating 
the ureter and the use of a blunt hook or 
forceps above the stone will prevent its 
escape upwards. 

There is some difference of opinion as to 
the necessity of suturing the ureter. Of 
those who expressed themselves, most 
authors were in favor of placing a few in- 
terrupted sutures when possible. Some 
thought it advisable to place a catheter 
through the bladder up to the kidney pelvis 
following operation. Opinion was equally 
divided as to the necessity of suturing the 
vaginal incision. In the presence of infec- 
tion, it should be left open ; and when closed, 
drainage should be provided. 

It is practically agreed that the operation 
should be done only in those cases where 
the stone is easily palpable and where there 
is sufl^cient vaginal relaxation to allow ample 
exposure and easy manipulation. That is 
not thoroughly in accord with the views of 
Lower<-"', who has stated that his "ex- 
perience includes nulliparous as well as 
parous women and the removal of stones 
which were so high that their palpation was 
barely possible." Igron also reports the va- 
ginal removal of a ureteral calculus in a 
virgin, but states that it was necessary to 
inci.se the hymen in three places. 

Poaaihle Operative DifficiiUicf<: The diffi- 
culties that may arise are similar to those 
that may occur in the removal of a stone 
from any portion of the ureter. 

1. The stone may slip up or down the 
ureter and away from the field of operation. 
Five cases are on record in which this has 
happened, the stone slipping up the ureter 
and requiring removal through an abdomi- 
nal incision. Lower'^"' has reminded us 
"that anyone who has had much experience 
in the removal of smooth ureteral stones 
from a dilated ureter will have had cases in 
which the stone has moved away from its 
first location. Such changes in the position 
of ureteral stones are not confined to any 
type of operation." It must be admitted, 
however, that the vaginal incision here de- 
scribed cannot be enlarged upward to any 
great extent and it is impossible to examiiu- 
the ureter over much of its length or follow 

•'0 Lower W E.: Removal of Stone from Lower 
Ureter by Vaginal Route, J. Urol. 14:113, 1925. 



February, 1940 



VAGINAL URETEROLITHOTOMY— COBB 



73 



a stone upward as can be done through an 
abdominal incision. With the technique now 
employed the danger of a stone moving up- 
ward is greatly lessened. 

2. Severe hemorrhage may occur. The 
only such instance of this is recorded by 
Bloch*^". The bleeding was so free that tam- 
ponment was necesary. He later removed 
the vaginal tampon, freed the ureter and 
e.xtracted the stone. Robinson, in using the 
approach described by Doyen*"" of incising 
the anterior culdesac and .separating the 
bladder from the uterus, found it necesary 
to 11 gate the uterine artery. 

3. The error of inadvertently opening 
the peritoneal cavity is not mentioned in any 
of the reports that have appeared in the 
literature. It did occur in one of our opera- 
tions. After having performed three of 
these operations with such gratifying re- 
sults, the fourth was done with much en- 
thusiasm. This was a borderline case in 
which the stone was rather high and barely 
palpable. The stone was removed through 
the vaginal incision, but, in freeing the 
ureter, the peritoneal cavity was opened. A 
fatal peritonitis developed, either from con- 
tamination from the vagina, or, more likely, 
from the infected urine. 

4. The accidental opening of the bladder 
occurred in two of our cases. This was im- 
mediately recognized, and the opening was 
closed. In one case there was no post-oper- 
ative urinary drainage from the vagina; in 
the other case there was some drainage of 
urine for five days. This complication has 
also been described by Shaw,'--' who states 
that "if the operator keeps the relationship 
of the base of the bladder, cervix and ureter 
in mind, this accident should never occur. 
The bladder can be readily avoided by inclin- 
ing the dissecting finger laterally and pos- 
teriorly and approaching the ureter on its 
lateral and posterior aspect. In other words, 
when the stone is felt, it should be medial 
and anterior to the dissecting finger." 

Post operative urine druinuae uiid fistida: 
Israel,'-'" Doyen,""' and others have advo- 
cated the use of an indwelling ureteral 
catheter following operation. From a study 

21. Bloch, A.: Ueber Ureteroperation, Folia 
Urolog. 3;589, 1908. 

22. Shaw, E. C: Vaginal Ureterolithotomy, J. 
Urol. 35:289-299, 1936. 

23. Israel, J.: Ueber Operationen wegen Ureter- 
steinen, Folia Urolog., 7:1, 1912. 



of the collected cases, however, it does not 
appear that this materially affects the post- 
operative drainage of urine. We have used 
this ureteral catheter post-operatively in 
four cases, but do not believe it necessary. 
In two of these four cases, there was no 
drainage of urine from the vagina ; in one 
there was leakage of urine for six days ; and 
in the fourth there was drainage for seven 
days before death resulted from peritonitis. 
In the two remaining cases the ureteral cath- 
eter was not used post-operatively. In one of 
these there was no leakage of urine, while 
in the other urine drained vaginally for five 
days. Many authors do not state whether 
post-operative urine drainage through the 
vagina occurred or not. But from a study 
of these cases it would appear that when it 
did occur, it was not prolonged. Lower'-"' 
states that there "is not likely to be" any 
leakage of urine post-operatively, and that 
some of his patients were able to leave the 
hospital three or four days after operation ; 
however, in one of these cases there was 
drainage of urine for 21 days — the longest 
time reported. Barney and Chute'-" have 
reported that in those patients whose ureter- 
al stones were removed through one of the 
abdominal routes, "the urinary fi.stula per- 
sisted an average of 16 days." It is clear 
that the period of urinary drainage follow- 
ing vaginal ureterolithotomy compares mo.st 
favorably with that which follows the re- 
moval of these stones through any other in- 
cision. 

The likelihood of a permanent urinary 
fistula following the operation has apparent- 
ly been exaggerated. Young"' refers to 
"the frequent persistence of fistulae after 
the vaginal incision"; yet this did not occur 
in any of the 80 cases studied. In Cabot's 
case '-■''' it appears that a functionless pyo- 
nephrosis existed on the same side of the 
ureteral stone ; for the moment the stone was 
removed there was a gush of pus from above. 
He introduced a rubber tube into the ureter 
through the vagine and left it in place for 
some time; after removal there was no tend- 
ency for the opening to close, and there 
was a constant, moderate discharge of pus 

24. Barney, J. D., and Chute, R.: Management of 
Calculi in Lower Ureter, J. Urol. 25:173, 
(March) 1931. 

25. Cabot, A. T.: Successful Case of Ureterolitho- 
■fom'v "for an Impacted Calculus, Boston M. & S. 
J. 122:247, 1890. 



74 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 







>■ 
< 
O 

J 
< 

si 

« 



z 


Rapid Con- 
valescence 

18 Days 

3-4 Days 

12 Days 

4-5 Days 

2 Weeks 

1-10,1-5, 1-2 Mos., 

10 Days, 1-12 Days 

Not Stated 

17 Days 

7 Days, 11 Days 


>" 
s 



K 


I 
h- 
I] 



n 

E < 


^ r 1 


UJ 

L; 


J 


1 

S : ° S : :: = 5 S = = = : . 


i 

z 



< 


his 

2 S" 


1 111 
o o o o 


u. 


IS) 
(0 


fi 

U ta. 




O 

;2 


< 



Q 
Ul 

tt 

Q. 
bi 

u. 





c 

>! - - z ^z>i- z j„ - z>, z >,---- z ^ sz>,z>, 


o 
o 

I 
1- 
u 

s 

> 

< 

E 
u 
a 




Si 

»- 5 u 

0. 


II 1 
o o o 

Z z z 




z 




. 1. 

■ o 

^ »< - 
; z 5 
~ J >- 

5z 

• o 


cn 


-1 

01 


tE 
< 
U 

> 


'^C0WiCt-N'^eDOQCMC0O^<-<0lTl'C)C0C0M"T}tt-t-ai01'-'»HCQClUSt0OO'--'CJWW(D50tS<0t-lr-t-01 
OOo00100lOi010jOOiOCiOOOOf-<OoOOoOOOO<-(r-ti-i.-tCaNcOCOCCCOfOCOCOCCCOeOCCCOCCCO 




■ 
< 


1-t 00 








< 

U 
& 



OS *^ 

hi ih 1 ilil* ililJillilTiliiki.liiil Jill 

W«Q UU^ fe MnSki« .2;x.,^osJUD5>m«KSCJeQCa.6:.-^i:.SCQ5:K7-.E=:-< 1 



Fcbruaiy, 1940 



VAGINAL URETEROLITHOTOMY— COBB 



75 



through it; but no urine ever came through 
the fistula. 

Mortality : In the 80 cases of vaginal 
ureterolithotomy thus studied, there were 
four deaths, only two of which seemed to be 
directly attributable to the operation. One 
case was reported by Munde, who made no 
statement as to the actual cause of death. 
The other case was the fourth of our series 
in which death from peritonitis resulted 
from inadvertently opening the peritoneum. 
One of Kelly's patients died some years after 
the operation, but autopsy revealed that 
death was due to intra-abdominal adhesions 
incident to opening the abdomen at the time 
of the vaginal ureterolithotomy. This death 
should be attributed to the abdominal oper- 
ation rati er than to the vaginal. A patient 
reported by Jaboulay also died, but in this 
case he performed pyelonephrotomy in ad- 
dition to vaginal ureterolithotomy. Un- 
doubtedly this more formidable procedure 
contributed to this death. 

Comment 

Those who have had experience with 
vaginal ureterolithotomy commend it as the 
most satisfactory operation. It is admirably 
suited in obese, parous individuals. The con- 
sensus of opinion is that this operation 
should be reserved for those cases in which 
on vaginal examination the stone is readily 
palpable and there is sufficient relaxation to 
permit adequate exposure. The procedure 
of incising the hymen in several places or 
making an incision through the muscles of 
the pelvic floor extending to the tuberosity 
of the ischium is not particularly attractive. 
The operation should not be undertaken until 
after cystoscopic manipulation has been 
tried. The ea.se with which the operation 
can be accomplished to both operator and 
patient should justify its use earlier in the 
treatment of lower ureteral stones in women 
rather than prolonged cystoscopic treat- 
ments when little progress is being made. 
This is particularly true in those cases in 
which a severe infection is present and 
cystoscopic maipulations are poorly toler- 
ated. In such patients the operation may 
be truly life-saving. 

Conciliations 
On a basis of personal experience with six 
such operations and from a study of 74 cases 



reported in the literature, the following con- 
clusions, which are in accord with the views 
expressed by Lower,*^"* may be drawn: 

1. Vaginal ureterolithotomy is a compar- 
atively simple method of removing a stone 
from the lower ureter, a location which 
makes other methods difficult. 

2. It should be reserved for those cases 
in which stones are readily palpable on 
vaginal examination and in which there is 
sufficient vaginal relaxation to assure ade- 
quate exposure. 

3. It affords dependent drainage should 
urinary leakage occur. 

4. The possibility of a permanent uretero- 
vaginal fistula seems to have been exagger- 
ated. It did not occur in these 80 cases. 

5. An external incision with the attend- 
ant possibility of hernia is avoided. 

6. The period of convalescence is short- 
ened. 

Discnasion 

DR. HAMILTON W. McKAY (Charlotte): I can't 
add anything to what the author of this paper has 
said. I have had a very hmited experience with 
vaginal ureterolithotomy — three cases only — in all 
of which I used the technique which Dr. Cobb has 
outlined and advocated, making the incision directly 
over the line of the ureter when the stone is dis- 
tinctly palpable in the vagina. All three of these 
cases made an uneventual recovery. 

I do want to bring to your attention and to con- 
demn prolonged cystoscopic operative procedures in 
the removal of stone from the intra-ureteral por- 
tion of the ureter. You ask me why I condemn 
that procedure. If you remember the anatomical 
relationship of the cervix, the bladder, and the 
ureter, you know that the lower ureter is richly 
supplied with lymphatics. It is a misnomer to use 
the term "cystoscopic manipulation" in connection 
with the modern operative instruments used with 
the cystostope upon a stone that fits snugly in the 
lower ureter. The mucous membrane is usually 
broken. Infection enters through the lymphatics 
causing a supperative nephritis which often ends in 
death. 

I think the author has shown what fine surgery 
is- being done in Madison County and in all parts 
of North Carolina. This- is the second time I have 
heard Dr. Cobb speak on this subject, and I am 
treniendously interested in the fact that he is popu- 
larizing an operation that is essentially practical. 

DR. D. J. ROSE (Goldsboio): I would like to 
thank Dr. Cobb for a very interesting paper. Every- 
body who practices medicine will sooner or later 
have patients with stones in the pelvic portion of 
the ui-eter. 

Anything that I might say relative to the vaginal 
route for removing stones in the pelvic portion of 
the ureter is information which I obtained first- 
hand from Dr. Cobb, and I am very grateful for 
this valuable information. 

I have had six or eight cases of vaginal ureter- 
orolithotomy since Dr. Cobb allowed us the privilege 
of .seeing how this operation was done. In this small 
series I have not had a complication: no urinary 
drainage, no hemorrhage, no infection, and no 



■n 



76 



NORTH CAROLINA MEDICAL JOURNAL 



February. 1940 



deaths. I know of no operation which makes a sur- 
geon feel better this this operation. 

There are two or three things which Dr. Cobb 
has rapidly mentioned which I would like to call to 
your attention as it was taught to me by him. 
One thing is that you must have free access to the 
upper vault of the vagina. Another is that good 
\nsibility is necessary. For that reason I do the 
operation as it was taught me by Dr. Cobb, but I 
do not use any dyes. I have been injecting into 
the introitus of the vagina a small amount of ade- 
nine chloride. This gives, I think, a little better 
visibility. Then, as Dr. Cobb said, a blunt hook 
or AUis forceps is passed around the ureter above 
th« stone. 

I certainly would not take issue with the author 
of this paper, but there is one thing that I believe 
is an advantage, certainly to me, and that is the 
handling of the ureter with a finger. You c.in evalu- 
ate the pressure or the pull that you have on the 
ureter better T^ith your finger; and by basing your 
finger above the stone you can prevent the stone 
from slipping back up the ureter. 



A CASE OF AIXHUM TREATED BY 

LUMBAR SYMPATHETIC 

GANGLIONECTOMY 

Complete Bibliography 

R. B. Mcknight, M.D. 
Charlotte 

Case Report 

A colored male laborer, age about 45, was 
referred to me through the courtesy of Dr. 
A. G. Brenizer. His history was irrelevant 
except for the condition of his feet. There 
had been no other similar condition in his 
family to his knowledge. He did not know 
exactly when the trouble began, but it was 
evidently about a year before admission. 
Although an illiterate negro, he described 
the onset clearly by stating that it looked 
and felt as if a string had been tied tightly 
around the base of each little toe. About 
three months before admission both little 
toes had become gangrenous and had "fallen 
off". The process had involved a second toe 
on each foot with a similar onset. These, 
too, had fallen off, leaving in each instance 
a foul, ulcerating base. At first there had 
been some pain, which subsided as the 
process extended and the affected toes lost 
most of their sensation. When the patient 
was seen, there was some annoying, but not 
severe, pain. . 

Examination revealed a well developed, 
sturdy negro male. Findings were entirely 
negative except for the feet. On the right 
foot the middle and little toes and on the 
left the fourth and little toes were missing, 



leaving ulcerated bases from which was pro- 
jecting in each instance some necrotic bone. 
The odor was quite offensive. With the ex- 
ception of callouses, expected in a colored 
laborer and not as marked as sometimes seen, 
the feet were otherwise negative. Pulsation 
in the dorsalis pedis arteries, as well as in 
other palpable arteries, was normal. Blood 
pressure was within normal limits. Sero- 
logical reactions for syphilis were negative. 
Urinalysis and blood sugar were normal. 
There was no evidence or history of tuber- 
culosis. Thermocouple studies of the skin 
temperatures before, during and after arti- 
ficially induced fever showed no impairment 
of the circulation in either the feet or the 
unaffected toes, eliminating, of course, cal- 
loused areas. In other words, he was ap- 
parently a healthy normal man, except for 
the above findings. 

We were at a loss in diagnosis. Debride- 
ment of the areas followed by conseiwative 
treatment (hot applications of boric acid 
solution, etc.) did not lead to any appreciable 
improvement. After ten days the economic 
phase of the case led us to perform sympa- 
thectomy and ganglionectomy of the lumbar 
sympathetic trunks. Under spinal anesthesia, 
using the transperitoneal approach, resec- 
tion of the second, third and fourth lumbar 
s\Tnpathetic ganglia and the intervening 
trunks with section of the communicating 
rami, was performed. Postoperative con- 
valescence was entirely unincidental. The 
temperature of both lower extremities was 
raised several degrees, the ulcerated areas 
healed with remarkable rapidity, and the 
patient was dismissed from the hospital after 
two weeks to go to his home in a neighbor- 
ing town. We still had not made a diag- 
nosis ! 

On an occasion some nine or ten months 
later, when perusing a text on the Practice 
of Medicine, my eye fell on a short para- 
graph entitled "Ainhum". The diagnosis 
then dawned upon me, as the man's story, 
and to a large extent his clinical course, were 
classical. Efforts were made to trace him 
for a check-up and photographs of his feet, 
but to no avail. I learned subsequently that 
he had served a term on the chain gang at 
hard labor for running afoul of the law. All 
efforts to make contact with him have failed. 

1. da Silva Lima, J. F.: Estudo sobre o ainhum, 
Gaz. Med. de Bahia, No. 1, 1867. (Quoted 
by various authors). 



February, 1940 



CASE OF AiNHUM— Mcknight 



77 



Ainhum 

Ainhum was first described by da Silva 
Lima*" of Brazil in 1867, although Messum 
in 1821 reported a case in the Lancet''''^ 
and Clark in 1860 reported a case of "Dry 
Gangrene of the Little Toe"<^>. In Brazil it 
is called "ainham" or "quiglia" and the 
Hindoo name is "sukha pakla", meaning dry 
suppuration*'". Bloom and Newman, quoting 
Rowens, state that the name ainhum is de- 
rived from the Yorulia dialect and means 
"a saw or file."<=' Matas'"' claims its origin 
is in Brazil and means a "fissure". Howard 
Fo.\ has heard the name ainhuyyi used by the 
Nagos, the African Negroes, among whom 
this condition is most frequently found, and 
he has chosen the name from all other names 
he heard because it designates best the mor- 
bid process and the natural termination of 
the malady — namely, the slow separation of 
the affected toe.*'" 

The disease, also called "dactylolysis spon- 
tanea", is a tropical or semi-tropical disease, 
chronic in nature, affecting chiefly males, 
and occuring usually in dark skinned races. 
(Grschebin, however, reported a case in an 
18 year old Russian.*") It is characterized 
by spontaneous amputation of the fifth toe, 
with involvement, in some cases, of the 
fourth toe, and very rarely of others. A 
constricting band, or line of demarcation, 
gradually forms at the proximal interphalan- 
geal joint, usually of the fifth toe, deepening 
its furrow until complete amputation occurs. 
This is often the only evidence of the disease 
and is pathognomonic.*"* 

The etiology is obscure. Numerous etiolo- 
gies have been proposed: leprosy, injuries, 
chiggers, trophoneurosis, scleroderma, 
heredity, syphilis, yaws, wearing of toe rings, 
infection, and so on. None are satisfactory, 

2. Messum, G., in Lancet (Apr. 25) 1821. 
(Quoted by various authors). 

3. Clark, in Tr. Epidemiol. Soc, London 1:105, 
1860 (Quoted by various authors). 

4. Gould and Pyle: Anomalies and Curiosities 
in Medicine, Philadelphia, W. B. Saunders, 
1900. 

5. Bloom, D., and Newman, B. ; Ainhum: Re- 
port of a Case with Roentgenologic Findings 
and Review of the Literature. Arch. Dermat. 
& Syph. 27:783-793, 1933. 

(J. Mata.^, R.: The Surgical Peculiarities of the 
Negro, Tr. Am. Surg. Assn. 14:483, 1896. 

7. Grschebin, S.: Observations on Ainhum: 
Does It Exist as an Independent Disease? 
Urol. & Cutan. Rev. 40:98-102, 1936. 

8. Makel, H. P.: Ainhum. Mil. Surgeon 66; 
693-695 (May) 1930. 



except, perhaps, for individual cases. Well- 
man*«>, Makel*", Weinstein*"", Bloom and 
Newman*^' and others have offered excellent 
critiques of the various etiological sugges- 
tions. Horwitz and Tunick*"*, Weinstein*'"' 
and other observers have noted the fre- 
quency in familial occurrences. 

The pathology may be considered from 
two view points: the primary lesion and 
secondary results. Babler*'-', quoting Unna, 
considers it a primary degeneration of the 
epidermis — a sort of ring-formed scleroder- 
mis, with callous formation of the epidermis, 
leading to secondary total stagnation necro- 
sis. From a roentgenologic standpoint, 
Friedman*"' considers it probably a trophic 
lesion with atrophy and destruction in the 
distal phalanges. The end result is what 
one would expect in a constricting process: 
ischemia and anoxemia followed by total 
tissue death. 

The diagnosis should not be difficult, as 
the constricting ring is pathognomonic of 
the disease. 

Regarding treatment, most observers agree 
that division of the constricting ring does 
not always stop the process; they also agree 
that ultimate amputation of the toe or toes 
is advisable. Some patients complain of 
severe pain, and sodium iodide intravenous- 
ly has been recommended for the relief of 
this pain*'" ; it has no curative effect. We 
can find no report in the literature where 
surgery of the sympathetic nervous system 
has been utilized in attacking the disease. 

Incidence in North Carolina 

It is interesting to note that this patient, 
who had always lived in North Carolina, is 
the third to be reported from the state. 
Hornaday, in 1881, reported a case of ain- 

9. Wellman, F. C: A Criticism of Some of the 
Theories Regarding the Etiology of Goundou 
and Ainhum, J. A.M. A. 40:636-638 (Mar. 3) 
1906. 

10. Weinstein, H.: A Description of Ainhum as 
Seen in the Canal Zone with Report of In- 
teresting Cases Occurring in One Family, 
South. M. J. 6:651-656, 1913. 

11. Horwitz, M. T. and Tunick, I.: Ainhum. Re- 
port of Six Cases in New York, Arch. Dermat. 
& Syph. 36:1058-1063 (Nov.) 1937. 

12. Babler, E. A.: Ainhum, Ann. Surg. 48:110- 
114, 1908. 

13. Friedman, L. J.: Roentgen Findings in Ain- 
hum, Am. J. Roentgenol. 31:349 (Mar.) 1934. 

14. Irgang, S. and Alexander, E. R.: Iodine 
Therapy for Relief of Pain in Ainhum, Arch. 
Dermat. & Syph. 30:508-509, 1934. 



NORTH CAROLINA MEDICAL JOURNAL 



February. 1940 



hum in a 10 year old negro girl.*''' He also 
cited a previous report by Pitman of a case 
in an adult negro male. Royster recently 
told me he had seen and treated, but had 
not reported, a case of ainhum in a colored 
man some thirty years ago in St. Agnes Hos- 
pital. Raleigh, N. C.'"" Bloom and New- 
man's case, seen in the dermatologic clinic 
of Bellevue Hospital, was a 39 year old 
negro man who had been born in North Car- 
olina and had lived here for twenty-seven 
years before going to New York.''* Cases 
have been reported from Philadelphia and 
Canada in negroes of North Carolina an- 
tecedents.'" While this disease is a tropical 
or semi-tropical malady, occurring chiefly in 
Africa, Brazil and India, it may occur else- 
where in temperate climates or even in 
cold climates. It seems that more afflicted 
negroes have been reported from North Car- 
olina directly, or from North Carolina an- 
tecedents, than from the other Southern 
states, except, perhaps, the Gulf states. 
Discussion and Rationale of Sympathectomy 

While it is true that the diagnosis in this 
case was made subsequently to observation 
and treatment, there is no doubt as to its 
accuracy. The pathognomomic sign was 
stressed by the man, and there were no other 
complaints except the non-healing ulcers, 
which were undoubtedly a progress of his 
trouble. There is evidence that in some ca.ses 
the disease is not arrested by amputation of 
the toe, but that it continues to progress. 
Such was the condition here. Efforts to se- 
cure healing of the areas within a reasonable 
time were unsuccessful ; hence, in the ab- 
sence of a definite diagnosis, lumbar sympa- 
thectomy was done. The rapid recovery fol- 
lowing operation and the fact that the man 
served a chain gang term at hard labor is 
some evidence that a cure was obtained. 

I cannot say that lumbar sympathectomy 
and ganglionectomy are indicated in the 
treatment of ainhum. What would sympathy 
have accomplished in the earlier stages of the 
disease, during the constricting phase before 
the toes came off? Would it have prevented 
extension of the process? I do not know the 
answers, but do believe the second question 
can be answered in the affirmative. I have 
performed lumbar sympathectomy and gan- 
glionectomy for thrombo-angiitis obliterans, 

(15.) Hornaday, E. H.: Ainhum, North Carolina 

M. J. 8:116 (Sept.) 1881. 
(IG.) Royster, H. A.: Pei-sonal communication. 



Raynaud's disease, spastic paralysis, and in- 
tractable ulcers, with results both good and 
indifferent. In this instance, however, the 
results were nothing short of phenomenal. 

Perhaps it may be contended that an oper- 
ation of so formidable a nature is hardly 
justified for such a local condition. I am not 
sure that such a contention is entirely sound. 
I used the transperitoneal approach to the 
lumbar sympathetic chain, but since have 
used the extraperitoneal route, which is a 
safer operation. Provided the surgeon will 
use care against injury to the great vessels 
(the aorta on the left and the vena cava on 
the right), localize and get the ureters out 
of the way, and observe a meticulous hemo- 
stasis, especially deep in against the vena 
cava, I see little danger in the operation. 

The rationale of the operation is rea.son- 
able. The physiologic response is that of 
increased blood supply to the legs by elimi- 
nating (partially at least) the vasoconstric- 
tion action of the sympathetic fibres to the 
musculature of the blood vessel walls and 
allowing thereby vasodilation, with a result- 
ing increased influ.x of blood. 
Smnmary 

1. A case of ainhum occurring in a native 
North Carolina colored man is reported. 
Another case observed previously by a col- 
league is also reported, making a total of 
four cases of this disease reported directly 
from North Carolina. 

2. Brief reviews of the incidence and na- 
ture of the disease are presented. 

3. This is apparently the first time ainhum 
has been treated by lumbar sympathetic gan- 
glionectomy. The results were all that could 
be desired. No claim is advanced that this 
form of surgery is indicated in all cases of 
ainhum, but it would seem that in advanced 
and intractable cases lumbar sympathetic 
ganglionectomy is the ideal form of treat- 
ment. 

4. What we believe to be a complete bibli- 
ography is appended. 

Bibliography of Ainhum 
(Grateful acknowledgment is made to 
Mrs. Helen Monahan and Mrs. Louise Pat- 
ton, Librarian and Assistant Librarian of 
the Charlotte Medical Library for their un- 
tiring assistance in the preparation of this 
Bibliography. Some texts on di.seases of the 
skin have been included ; references to ain- 
hum in the general medical texts are not 



February, 1U40 



CASE OF AiNHUM— Mcknight 



7U 



10. 



11. 



12. 



included. We believe it is about complete 
and hope it will be of service to the physician 
who is interested in this curious disease.) 

1. Abbe, T.: Two Case.s of Ainhum, M. Rec. 79: 
478-480 (Mar. 18) 1911. 

2. Acton, H. W.: Ainhum, Band Scleroderma, 
Indian J. M. Research 15:1085-1090, (Apr.) 
1928. 

:>. Alexander, D. M. and Donaldson, R.: Ainhum, 
Lancet 2:858, 1906. 

4. AUdrcdge, R. H.: Ainhum (Dactylolysis 
Spontanea), J.M.A. Alabama 6:137-141 (Oct.) 
19.36. 

5. d'Almeida, D.: Sobrc a pathogenia do ainhum, 
Gaz. S. Paulo 3:312-326, 1905. 

6. Alves de Lima and Rubiao Meira: Contribu- 
tion a Tctudo dc I'etiologic de I'ainhum, Gaz. 
clin. S. Paulo 3:148-151. 1905. 

7. Anderson, H. B.: Ainhum, Canada Lancet 34: 
470, 1900-1901. 

8. Andrews, G. C: Diseases of the Skin, Phila- 
delphia, W. B. Saunders Co., 1930. 

9. Argaud, R. and Brault, J.: Contribution a 
IVtude de I'anatomia pathologique et de la 
pathogenic de I'ainhum, Bull. Soc. path. exot. 
7:371-375, 1914. 

Argaud, R. : Osteolvse ainhumique, Bull. Soc. 
path. exot. 25:323-325, 1932. 
Ashlev-Emile, L. E.: On the Etiology of Ain- 
hum, J. Trop. Med. 8:33, 1905. 
Ashlev-Emile, L. E.: On the Etiology of Ain- 
hum, South African M. Rec. 7:116-118, 1909. 

13. Aubry, G.: Cas' d'ainhum chcz un european, 
Bull, et mem. Soc. med. d. hop. de Paris 
.54:1361-1363, (July 21) 1930, 

14. Babler, E. A.: Ainhum with Report of a Case, 
Ann. Surg. 48:110-114, 1908: also Quart. Bull. 
M. Dept. Wash. Univ. pp 31-36, 1907-1908. 

15. Barton, S. S.: Case of Ainhum, J. R. Nav. 
M. Serv. 4:422. 

16. Bass, J. M.: Ainhum with Report of a Case, 
Nashville J. M. & S. 84:201-206, 1898. 

17. Bennett, C. R.: Ainhum (Dactvlolvsis Sponta- 
nea) J.M.A. Georgia 27:52-54 (Feb.) 1938. 
Beinardeaux, M.: Three Caftes of Ainhum. 
Province med. Paris 23:440. 1912. 
Besnier, E., Brocq, L. and Jacquet, L. : Prac- 
tique Dermat. : cited by Grschebin. 
Bharucha. E. S.: Ainhum, Case, Indian M. 
Gaz. 52:403. 1917. 

Bijon. R. : Note sur un cas d'ainhum, Bull. 
Soc. path. exot. 8:570, 1915. 

22. Bloom. D. and Newman, B. : Ainhum: Report 
of a Case with Roentgenologic Findings and 
Review of the Literature. Arch. Dermat. & 
Svph. 27:783-793 (May) 1933. 

23. Blum, H. N.: Ainhum. Report of a Case (Re- 
view of Literature), M. Rec. 66:651-653. 1904. 

24. Bordier, quoted by Matas: Tr. Am. Surg. 
Assn.. 1896. 

25. Branden, F. van den and Appelmans, M. : La 
pathogenie de I'ainhum, Ann. Soc. beige med. 
troo. 12:160-172. 

26. Brayton, N. D.: Ainhum. with Report of a 
Ca.se, J.A.M.A. 45:87-89 (July 8) 1905 

27. Bredian, A. -J. -B. -M.: Etude slir I'ainhum, 
Bordeaux, 1881; abstracted, Gaz. d. hop. 62:936- 
938, 1889. 

28. de Brun, H.: L'ainhum, Semaine med. 14:394- 
397, 1894. 

29. de Brun, H.: L'ainhum des autcurs constitue- 
til une entite morbide distincte ou bien n'est-il 
med. Paris 3 s. 36:348-374. 1896. 

30. de Brun, H.: Contribution nouvelle a I'etude 
de la question de l'ainhum, Ann. de dermat. 
et syph. 3 s. 10:325-330, 1899. 



18. 



19. 



20. 



21. 



31. Brunon: Cas d'ainhum avec presentation de 
photographies. Bull. Soc. de med. de Rouen 
23 s. 3:39, 1890. 

32. Bussiere, J. A.: Cas d'ainhum observe a Pon- 
dichery, D'hyg. et de med. colon. Paris 7:214- 
219, 1904. 

33. Butler. H. W.: Ainhum (Dactylolysis Spon- 
tanea), M. Clin. North America 9:1181-1185 
(Jan.) 1926. 

34. Camuset: (Do ainhum) algumas consideracoes 
soble esta molestia. Bull. Soc. de med. de Paris 
11:92-94, 1877. 

35. Cannae, in Ai-ch. d. parasitol. 9:269, 1905; 
cited by Keen. 

36. Castellani, A. and Chalmers, A. J.: Manual 
of Tropical Medicine, London, BalUere, Tindall 
& Cox. Ltd., 1919. 

37. Chalmers, A. J., in Lancet 1:20 (Jan. 6) 1900; 
cited by Keen. 

38. Clark: Ainhum, Tr. Epidermol. Soc. 1:105, 
1860. 

39. Cognes: Observation d'un cas d'ainhum a 
Madagascar, Arch, de med. nav. 51:232-236, 
1889. 

40. Callas. A.: (Dactylolysis spontanea) Arch, 
med. p. 357 (Nov.) 1867. 

41. Cooper, K. B.: Notes on a Case of Ainhum, 
Tr. M. & Phys. Soc. Bombay 3 s. 10:25-32, 
1887. 

42. Corrc. A.: Ainhum, maladies des pays chauds, 
Paris, Doin. 1887, p. 597. 

43. Crawford, D. G.: Notes on Four Cases of 
Ainhum, Edinburgh M. J. 31:1120-1123 (June) 
1886. 

44. Crawford, D. G.: Ainhum, Indian M. Gaz. 44: 
337, 1909. 

45. Crombie, A. Ainhum, Tr. Path. Soc. London 
32:302-304, 1881. 

46. Dalgetty. A. B.: Ainhum, J. Trop. Med. 2: 
193, 1899-1900. 

47. Dantec, A., cited by Blum: M. Rec. 66:651. 

48. Darier: Precis dc Dermatologie, 1928; cited 
by GrschebinC-'). 

49. Day, R. H.: Ainhum, Med. News 53:348-350, 
1888. 

50. Delamare, G. and Architonv: Histopathology 
of Paraleprous Ainhum, Bull, et Mem. Soc. 
med. d. hop. de Paris 47:218-221 (Feb. 9) 1923. 

51. Delanoe. L.: Cas d'ainhum. Bull. Soc. path, 
exot. 25:322-323, 1932. 

52. Delanoe, L. : Sur un cas de maladie d'ainhum 
ayant intereess'e la jambe droite. Bull. Soc. 
path. exot. 18:470-474, 1925. 

5.3. Delanoe, L. : Sur un cas d'ainhum chez une 
femme niarocaine. Bull. Soc. path. exot. 17: 
482-484. 1924. 

54. Dell'Orto, J.: Ainhum, New Orleans M. & S. 
J. n.s-. 8:516-518, 1881. 

55. Despretis, L.P. : Etude sur l'ainhum, Mont- 
pellier, 1873. 

56. Digby, C: Ainhum on the West Coast of 
Africa, Brit. M. J. 1:1331, 1891. 

57. Doyle, E. A. G.: Ainhum, Brit. M. J. 1:1346, 
1891. 

58. Dschang, Y. D.: Beitrag zur pathologischen 
Anatomic de Ainhum, Virchows Arch. f. path. 
Anat. 290:648, 1933. 

59. Dubreuilh, W. and David-Chausse: Cas d'ain- 
hum, Gaz. hebd. sc. med. Bordeaux 46:328, 
1925; also Bull. Soc. med. chir. Bordeaux 46: 
215-217, 1926. 

60. Duhring, L. A.: Case of Ainhum (with Mi- 
ci'oscopical Examination by Henr.v Wile), Am. 
J. M. Sc. n.s. 87:150-154 (Jan.) 1884. 

61. Dupouy, E.: Une observation d'ainhum. Arch, 
de med. nav. 36:385-387, 1881. 



80 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



62. Dupouy, E. : Considerations sur I'ainhum, 
Arch, de med. nav. 41:260-263, 1884. 

63. Dyer, I.: Ainhum. (Buck ed. Reference Hand- 
book of the Medical Sciences, ed. 3. New York, 
William Wood, 1913.) 

64. Evans, J.: Ainhum, Tr. South Carolina M.A. 
p. 93, 1887. 

65. Eyles, C. H.: Histology of Ainhum, Lancet 
2:576-578 (Sept. 25) 1886. 

66. Facio, A. A.: Review of Ainhum, with Radio- 
graphic Demonstration of its Bone Pathology, 
Proc. Intemat. Conf. Health Trop. Am. 1:533- 
546, 1925. 

67. Faivre: Ainhum, Arch. Demiat. & Syph. 20: 
621-628, (Nov.) 1929. 

68. Fernades, C: Casos de ainhum, Brazil-med. 
39:27, 1925. 

69. Fontan: Question de I'ainhum, Arch, de med. 
nav. 37:177-212, 1882. 

70. Fox, H.: Ainhum, Arch. Dermat. & Syph. 
20:621-628, (Nov.) 1929. 

71. Fox and Farquhar: On Certain Endemic and 
other Skin Diseases of India, London, 1876. 

72. F^nton, cited by Matasde). 

73. Fnedman, L. J.: Roentgen Findings in .\in- 
hum. Am. J. Roentgenol. 31:349 (March) 1934. 

74. Garcia-Marnix, S.: Ainhum, Rev. de med. 
cirug. de la Habana 20:381-385, 1915. 

75. Geschwind, H.: Cas d'ainhum, Arch de med. 
et phai-m. mil. 12:361-364. 1888. 

76. Gessner, H. B.: Case of Bilateral Ainhum, 
Am. J. Trop. Dis. 2:206, 1914. 

77. Giordano, M.: Caso di ainhum in Tripolitania, 
Ann. di med. nav. e colon 40:529-533 (Sept- 
Oct.) 1934. 

78. Gonzalex-Martinez, I.: Sobre un caso de ain- 
hum, Bol. as. med. Puerto Rico 8:1, 1910-1911. 

79. Goulart, Z.: Subsidio ao estudo do ainhum. 
Arch, brasil. de med. 2:325-333, 1912. 

80. Gould, G. M. and Pvle, W. L.: Anomalic? and 
Curiosities of Medicine, Philadelphia, W. B. 
Saunders Co., 1900, p. 828-832. 

81. Gross: Ainhum, Arch. Dermat. & Syph. 21: 
874-875 (May) 1929. 

82. Grschebin, S.: Observations on Ainhum; Does 
It Exist as an Independent Disease? Urol. 
& Cutan. Rev. 40:98-102 (Feb.) 1936. 

83. Guvot, F. : Apropos de I'ainhum, Arch, de 
med nav. 32:440-451; 34:298-304. 1880. 

84. Guvot, F.; Sur I'ainhum. Bull. Soc. anat. de 
Paris 55:623-634, 1880: also Progres med. 9: 
357-361, 1881. 

85. narrower. G.: Ainhum Disease and Anesthetic 
Type of Leprosv. Tr. Rov. Soc. Trop. Med. & 
Hyg. 29:73-76, (June) 1935. 

86. Heitzmann, C. : Reoort of the Special Com- 
mittee on Microscopic Examination of a Speci- 
men of Ainhum, Tr. Am. Dermat. A. 5:49-51, 
1881. 

87. Henderson, W. W.; Ainhum, Tr. M. & Phvs. 
Soc. Bombav, 1884, n.s. 6:18, 1885. 

88. Hermans, E. H.: Case of Ainhum, Nederl. 
tijdschr. v. genesck. 74:689, <Feb. 8) 1930. 

89. Hermans, E. H.: Ainhum, Nederl. tiidschr. v. 
eenee.sk. 74:1886-1891 (April 12) 1930. 

90. Herman.', E. H.: Six Cases of Ainhum in 
New York. ."Vrch. Dermat. & Svph. 36:1058- 
1063 (Nov.) 1937. 

91. Henick. J. B.: Ainhum. Chicago M. Ree. 13: 
363. 1897-1898; al.so Philadelphia, M. J. 1:246- 
248, 1898. 

92. Hen-ick. J. B.: Case of Ainhum, Med. Rec. 
1-246. 1898. 

93. Hill. R. C: Ainhum, New Orleans M. & S. J. 
81:509 (Jan.' 1929. 

94. Hine. A. E. B.: Well-Marked Case of Ainhum, 
Lancet 1:218 (Jan. 25) 1895. 



95. Hornaday, E. H.: Ainhum, North Carolina 
M. J. 8:116-118 (Sept.) 1881; also Tr. M. Soc. 
North Carolina 28:76-78, 1881. 

96. Hoi-witz, M. T. and Tunick, I.: Ainhum, Re- 
port of Six Cases in New York, Arch. Dermat. 
& Syph. 36:1058-1063 (Nov.) 1937. 

97. Horwitz, O.: Case of Ainhum Occurring in 
the Out-Door Surgical Department of Jeffer- 
son Medical College Hospital, Med. & Surg. 
Reporter 56:649, 1887. 

98. Hudellet, G. : Lesions osseuses dans I'ainhum, 
Arch, delectric. med. 32:292-299, 1922; alst> 
Bull. Soc. path. exot. 15:350-352, 1922. 

100. Hyde, J. N. and Montgomery, F. H.: Diseases 
of the Skin., ed. 7, Philadelphia, Lea & Febiger, 
1904, p. 608. 

101. Irgang, S. and Alexander, E. R.: Iodine 
Therapy for Relief of Pain in Ainhum, Report 
of a Case, Arch. Demiat. & Syph. 30:508- 
509 (Oct.) 1934. 

102. D. J. (K): Ainhum, Tijdschr. v. inland, ge- 
neesk. 8:41-43, 1900. 

103. Kaufman, L. R.: Ainhum, Am. J. Surg. 29: 
221, 1915. 

104. Kojima, T. and Ikari, T.: Casie of Ainhum in 
South China, Taiwan Igakkai Zasski no. 293, 
p. 48 (Aug.) 1929. 

105. Laurent and Hudellet: Ainhum, Bull. Soc. 
path. exot. 4:364-366. 1911. 

106. Lazard: Ainhum, Tulane Phagocyte (Jan.) 
1904. 

107. Long, J. H. : Ainhum. Long Island M. J. 4: 
205, 1910. 

108. Lopez, F.: Ainhum, Anal. d. Oftalmol. 7:309- 
316, 1904-1905. 

109. Love, A. C: Ainhum, with Report of a Case 
in Ascension Parish, Louisiana, Gaillard's M. 
J. 35:367-369, 1883. 

110. MacFarlane. N. M.: Ainhum, South African 
M. Rec. 5:70, 1907. 

111. McKnight. R. B.: A Case of Ainhum Treated 
bv Lumbar Sympathectomy. Complete Bibli- 
ographv. North Carolina M. J. 1:76-82 (Feb.) 
1940. 

112. Maass, E.: Beobachtungen uber Ainhum, Ai-ch 
f. Schiffs-u. Tropen Hyg. 30:32-34, (Jan.) 1926. 

113. Makel. H. P.: Ainhum. Mil. Surgeon 66:693- 
695 (May) 1930. 

114. Manson. P.: Tropical Diseases, London, Cas- 
sel & Co. Ltd., 1929. 

115. Manson. P.: .■Vinhum. Albutt's System Med. 
2:728-731, London 1907. 

Ufi. Mata.s, R.: The Surgical Pecularities of the 
American Negro, New Orleans M. & S. J. 16: 
603, 1896; Tr. Am. Surg. A. 14:483, 1896; also 
reprint. 

117. Maver. M. and Rocha-Lima: Ainhum, Aixh. 
Dermat. & Syph. 138:472. 1922. 

118. Menocal, R.: Enfer medad de ainhum. Rev. 
dc cein, Habana no. 3 p. 1, 1886. 

119. Messum. G.: Ainhum. Lancet 1:932. 1821. 

120. Miralut: Ainhum. quoted by Matas""". 

121. Monizde Aragao. E.: Ainhum. Rev. de med. 
et d'hyg. trop. 7:205. 1910. 

122. Moreiera, ,1. : Ein neuer nathologisch-anato- 
misvher und klinischer. Bcitrag zur Kenntnis 
des .Ainhums, Monatsh. f. prakt. Dermat, 
Hamb. 30:361-386. 1900: also reprints; al^o 
transl. (abst.) J. Trop. Med. 4:79-82, 1901. 

123. Moreiera. J.: A proposilo do ainhum. Brasil- 
med. 16:310. 1902. 

124. Moreira. J.: Ainhum (Cases) Rev, da soc. dc 
Med. r, chirurg. 6:261-272. 1902. 

125. Moreira. J. and .■^ustrepesilo. A.: Contribucao 
ao estudo do ainhum. Brasil-med. 22:161-171, 
1908. 



Kebruary, 1940 



CASE OF AiNHUM— Mcknight 



81 



126. Muir, J.: Notes on a Case of Ainhum in South 
Africa, J. Trop. Med. 6:75, 1903; 7:317, 1904. 

127. Nelton & Croswell: Ainhum from Egypt, Lan- 
cet 2:227 (July 23) 1893. 

128. van Niekerk, J.: Ainhum, South African M. 
J. 2:162, 1894-1895. 

129. Nunez de Villaricencio, E.: De la enfeniicdad 
dcnomina da ainhum o dactilolisia. An. v. Acad, 
decicn mcd. et de la Habana 15:336-395, 1878- 
1879. 

l.'Ul. Ohmann-Dumesnil, A. H.: Ainhum (Cases) 
Tr. M. Soc. Missouri 38:124-137, 1895; also 
Medicine, Detroit 1:202-209, 1895. 

131. Oliveira, S.: Quatro cases de ainhum (doenca 
da Silva Lima), Bahia med. 3:146-148 (May) 
1932. 

132. Onorato. R.: L'Ainhum, Arch. ital. sc. med. 
col. 1:268-297, 1920. 

133. Ormsbv, 0. S.: Diseases of the Skin, ed. 5, 
Philadelphia, Lea & Febiger, 1937. 

134. Ortiz V CofTigny, J.: Three Cases of Ainhum, 
Rev. med. cubana 11:347, 1907. 

135. Pachecco Mendes. A.: Memoria sobre o ain- 
hum. Rev. de med. 1:425, 1879-81; 2:425; 447; 
460, 1881-1883. 

136. Pardee, L. C: Ainhum Showing Spontaneous 
Amputation of the Little Toes of Both Feet, 
Tr. Am. Dermat. A., 1901, p. 198, 1902. 

137. Pardo-Castello, V. and Nestre, J. J.: Bol. de 
la Sociedad de Dermatol, y Sifilofr. Oct.. 1929. 

138. Pawlokskaja-Karyschewa: Case of sclerader- 
ma ainhumoides, Rus.>?. Zeitschrif. Haut. u. 
Gcschlechtsck 10:11, 1915. 

139. Pcyrot. .!.: Un cas d'ainhum, Marseille mcd. 
60:1278-1281, 1923. 

140. Pillay, .T. M.: Ainhum, Two Cases, Antiseptic 
2:425, 1905. 

141. Pineau, E.: Observation d'un cas d'ainhum in- 
digene union med. 36:678-681, 1883. 

142. Pineau, E.: Ainhum, Case, Bull. Soc. de med. 
de Paris 18:126-129, 1884. 

143. Pitman: Reported Case in Adult, cited by 
Hornaday(».'!). 

144. Probstein, J. G.: Ainhum, Ann. Surg. 88:885- 
889 (Nov.) 1928. 

145. Proust, M. A.: Ainhum, Gazette des Hop. 18: 

146. Pusev. W. A.: Principles and Practice of Der- 
matology, ed. 4, New York, D. Appleton & Co., 
192.5. 

147. Pvle, W. L.: Ainhum, M. News 66:85-88 
fJan. 26) 1895. 

148. Reclus, P. Amputations congenitales et ain- 
hum: Clin, et crit. chir. Paris. 1884; also 
L'Unioii Medicale, (Oct. 18. 23, and 25). 1883. 

149. Reclus. P.: Rapport sur une observation d'ain- 
hum. Bull, et mem. Soc. de chir. de Paris 
15:428-436, 1889; also Gaz. hebd. de med. 2 ff. 
36-345-.348, 1889; also abst. Baz d. hop. 62: 
559, 1889. 

150. Rho. F.: Ainhum, Mai. prc<lom. n. parsi. caldi 
e Temperati. 2:604-606, 1896. 

151. Rot-hefort. E.: L'ainhum, Gaz. hebd. de med. 
2 s. 18:769-772, 1881. 

152. Rodriquez Gongora, S.: Apuntes sobve el ain- 
hum o dactilotisia. Cron. med. quir. do la Ha- 
bana 8:214-225. 1882. 

153. Rolls. .T. A.: Ainhum, .I.A.M.A. 47:2092 (Dec. 
22) 1906. 

154. Rosenau, M. .1. and Anderson, J. F.: Ainhum. 
in Musser and Kelly: Handbook of Practical 
Treatment, Philadelphia, \V. B. Saunders Co., 
1911. 

155. Rouget, J.: Amputation.^? congenitalc et Ain- 
hum. Paris, 1889; also abstracted, Gaz. d. hop. 
62:936-938,1889. 

156. Rov. G. C: Case of Ainhum, Indian M. Gaz. 
15:247, 1880. 



157. 
158. 



159. 
160. 
161. 
162. 

163. 

164. 
165. 
166. 
167. 
168. 
169. 

170. 
171. 
172. 

173. 
174. 
17.5. 

176. 

177. 
178. 
189. 

180. 
181. 
182. 
183. 

184. 

185. 
186. 

187. 
188. 



Royster, H. A., quoted by McKnightdiD. 
Rualt, A.: Case d'ainhum. Bull. Soc. anat. de 
Paris 59:529, 1884; also Progres med. 2 s. 
1:399, 1885. 

Scherck, H. J.: Ainhum with Report of Two 
Cases, Med. Mirror 8:224-226, 1897. 
Schuppel, F. G.: Pathology of Ainhum, Vir- 

chows Arch, f path. Anat. 56: . 

Sen. H. M.: Ainhum of a Supernumerary 
Finger, Indian M. Gaz. 27:334, 1892. 
Sezary, A. and Gallot, H.: Ainhum, Bull Soc. 
franc, de dermat. et syph. 40:566-569, (April) 
1933. 

Shepherd, F. J. Short Account of the Disease 
Called "Ainhum" with the Report of a Case, 
Am. ,J. M. Sc. N. S. 103:137-140, 1887. 
Sibilia, D.: First Case of Ainhum in Ethiopia, 
Riv. osp. 29:93-105 (Feb.) 1939. 
Sibilia, D.: Roentgen Study of Case, Ann. di. 
radiol. e fis. med. 12:439-444, (Oct.) 1939. 
da Silva Lima, J. F. : Ainhum, Gaz. med. de 
Bahia, 1852. 

da Silva Lima, J. F. : Ainhum, Gaz. med. de 
Bahia 1:146 (Nov. 13) 1867. 
da Silva Lima, J. F.: Ainhum, Brit. M. J. 
1:14, 1880. 

da Silva. Lima, J. F.: On Ainhum, Arch. Der- 
mat. & Svph. 6:367-377 (Oct.) 1880; also Gaz. 
mcd. de Bahia 2 s 5:341-360. 1881; also Arch, 
de med. nav. 36:459-465, 1881; also 7:54-61, 
1882. 

da Silva, Lima, J. F. : Un caso excepcional do 
ainhum, Gaz. de Bahia 3 s. 2:205-208, 1884. 
da Silva Lima: Para a historia do ainhum, 
Gaz. med. de Bahia 38:356-359, 1906-07. 
Simon, K. M. B.: Ainhum, a Family Disease, 
.T, A. M. A. 76:590 (Feb. 26) 1921; also J. 
Trop. Med. & Hyg. 24:209, 1921. 
Sims, G. K.: Ainhum (Case), Bi-Month. Bull 
Univ. Coll. Med. 2:59, 1897. 
Smith, Q. C: Ainhum (Case) J. A. M. A. 
45:2015, 1905. 

Smyth. J.: Ainhum in Southern India. Tr. 
South. Indian Br. Brit. M. A. 1887-1888 2:77-80, 
1888; also Indian M. Gaz. 23:57, 1888. 
Smvth. J.: Distorted Feet from Case of Ain- 
hum. Tr. South Indian Br. Brit. M. A. 1887-88 
2:402, 1888. 

Snider: Ainhum, Arch. Dermat. & Syph. 20: 
139 (July) 1929. 

Soto, O. and RafTo, J. L. : Interesante caso de 
ainhum. Cron med. 36:373-378. 1918. 
Soto. O. and Raffo, J. L. : Primer caso do 
ainhum observado en et Peru, Siglo Med. 67: 
341 (May 8) 1920. 

Spencer. H. A.: Ainhum, South African M. 
Rec 5:103, 1907. 

Stclwagon. H. W.: Diseases of th« Skin, ed. 
7. Philadelohia, W. B. Saunders Co., 1914. 
Stilhvcll. A. L.: Ainhum, Tr. M. Soc. New 
Jersey, 1899, p. 404. 

Stitt. E. R.: Diagnosis and Treatment of 
Tropical Diseases, ed. 5. Philadelphia, P. Black- 
iston's Son & Co., 1929. 

Suchard: Examen histolotique d'un des doigts 
d'un enfants atteint d'ainhum. Bull. Soc. Anat. 
do Paris 56:691-693, 1881; also Progres med. 
10:100, 1921. 

Sutton, R. L.: Diseases of the Skin, ed. 4, 
St. Louis, C. V. Mosby Co., 1921. 
Sutton, R. L., .Ir. : Inherited Ainhum-Iike Hv- 
perkeratosis. Arch. Dermat. & Syph. 38:26-31 
auly) 1938. 

Tenorio Nieto, A.: Caso de ainhum. Rev. med. 
de Colombia 2:399-402 fMarch) 1932. 
Teixeira Garcia, A.: Contribuicoes para o 



82 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



estudo do ainhum, Cong. Rio de Jan. 2:57-59, 
1891. 

189. Toppin, J: Spontaneous Amputation of the 
Small Toe in Africans (Ainhum), Lancet 1: 
306, 1891. 

190. Trelat. XJ.: Amputations congenitales et ain- 
hum, Gaz. hebd. de med. 2 s. 28:102-113, 1891. 

191. Unna: Histopathology of the Skin, p. 1144, 
cited by Brayton'-"'. 

192. Van de Branden, F. and Appelmans, M.: 
Pathogenic de Tainhum. Ann. Soc. beige de 
med. trop. 12:161-172 (June 30) 1932. 

193. Vivie, A.: A propos d'Ainhum. Ann. d'hyg. 
et de med. colon. 8:145-148, 1905. 

194. Valerio, A.: Sobre uncaso de ainhum, Arch, 
brasil med. 14:605-608, 1924. 

195. Water.s, E. E.: Case of Ainhum, Indian M. 
Rec. 38:201, 1918. 

196. Weinstein. H.: Description of Ainhum as 
Seen on the Canal Zone, with Report of In- 
teresting Cases Occurring in One Family, 
South. M. J. 6:651 (Oct.) 1913; also Proc. 
Canal Zone M. A. 4:110-121, 1911-12. 

197. Welch, R. S. G.: Ainhum (Case), U. S. Nav. 
M. Bull. 21:353-355 (Sept.) 1924. 

198. Wellman, F. C: Advanced Case of Ainhum 
with Some Remarks on Sarcopsylla Penetrans 
as a Cause of the Disease, J. Trop. Med. 11: 
117, 1908. 

199. Wellman, F. C: Ainhum and Leprosy; a 
Critical Note, J. Trop. Med. 8:285, 1905. 

200. Wellman, F. C: Case of .Ainhum in Its 
Earlier Stages, J. Trop. Med. 8:342, 1905. 

201. Wellman, F. C: Criticism of Some of the 
Theories Regarding the Etiology of Goundou 
and Ainhum, J. A. M. A. 46:63"6-638 (March 
3) 1906. 

202. Wellman, F. C. and McFarland, J.: Inter- 
mediate Host in Ainhum, J. A. M. A. 48:243, 
1907. 

203. Wellman, F. C: Etiologie de I'ainhum, Rev. 
de med. et d'hyg. trop. 3:76-80, 1906. 

204. Wellman, F. C: Suggestion as to the Prob- 
able Relation of Chiggers to Ainhum, J. Trop. 
med. 1:31, 1906. 

205. Wheatland, M. F.: Ainhum, J. A. M. A. 45: 
631, 1905. 

206. Wigley, J. E. M.: Case of Hyerkeratosis 
Palmaris et Plantaris Associated with Ainhum 
— like Constriction of Fingers, Brit. J. Dermat. 
41:188-191 <May) 1929. 

207. Winckler. W. J.: Ainhum in British Guiana, 
Brit. Guiana M. Ann. p. 88, 1891. 

208. Wolff, B.: Ainhum (Case) Am. J. Dermat. & 
Genito-Urin. Dis. 3:3, 1899. 

209. Wright, L. T.: Ainhum; Report of a Case 
Oecuring in a Man with Syphilis, Urol. & 
Cutan. Rev. 28:135-139, 1924." 

210. Wucherer, 0.: Ueber Ainhum, eine de afrika- 
nischen Rasse eigentumliche Krankheit.sform, 
Virchchows Arch. f. path. Anat. 56:374, 1872. 

211. Wuncher, cited by da Silva Limad^'^. 

212. Zambaco Pacha: L'ainhum des auteurs con- 
stitue-t-il une entite morbide distincte ou bien 
n'est-il qu'une modalite de la lepro.^e? Bull 
Acad, de med. 3 s. 36:96-i:!2, 1892; Rev. med. 
pharm. 9:127; 143, 1896. 

213. Zambaco Pacha: Ainhum and Lcprosv, Tr. 
Inst. Leprosy Conf. 3:45, 1897. 

214. Zavattari, E.: Ainhum in Fezzan (Libya). 
Arch. ital. di. dermat., sif. 10:343-344 (April) 
1934. 



COD LIVER OIL TREATMENT OF 
BURNS AND WOUNDS 

Parker C. Hardin, :m.D. 
Monroe 

During the past five years the local use of 
crude or pure cod liver oil as a wound dress- 
ing, applied alone or combined with petro- 
latum or honey in ointment form, has at- 
tracted much favorable attention among 
European clinicians. The excellent results 
achieved by this method in the treatment of 
burns and clean and infected wounds of all 
types have been emphasized in nearly seven- 
ty foreign papers reporting studies involv- 
ing appro.ximately 17,000 patients. But the 
appearance of only a dozen papers in the 
American literature suggests that this wide- 
ly useful therapeutic procedure is still com- 
paratively unknown or untried in this 
country. 

This paper is based on observations made 
in the treatment of 84 cases with cod liver 
oil at the Ellen Fitzgerald Hospital. Hav- 
ing first used cod liver oil as an external 
dressing three and a half years ago, the 
author was so favorably impressed with its 
advantages that he has employed it exten- 
sively and with satisfaction in an increasing 
variety of surgical conditions during the past 
two years, and believes that it merits wider 
recognition by American surgeons. 

Historical Review 

The fat of all fishes including the cod, to- 
gether with honey, is mentioned by Pliny in 
the first century as an efficient cure for 
wounds, according to Lucke"' : and Schaer<-' 
states that crude cod liver oil has long been 
used empirically by fishermen for ti'eating 
wounds, frostbites, and skin lesions. As early 
as 1922 Heald<" employed cod liver oil in 
treating injuries, burns, and infected wounds 

Head before the Section on Surserv. Medical Sm-iety of Itie 
.•st.ite of Nortli Carolina, Bermuda Cruise, May 13. 1939. 

Tlie autlior wislie.s to tliank Drs. J. .1. <*.<»udeIoL'k. J. "W. 
Drmaiid. K. K. Xeesc. G. W. Smilli. and .1. G. Faulk of 
MonriH'. Dr. r. A. Rolt of Marsliville. and Dr. Orren Moore 
rif Charlotte for their eourtesy and ar^si-itanec in pennitling 
Ihe inclusion of their cases in this rejMirt. 

1. Lucke, H.: Wound Treatment with Honey 
and Cod Liver Oil, Deutsche med. Wchnschr. 
61: 1638 (Oct. 11) 1935. 

2. Schaer, H.: Erfahrungen mit Unguentolan, 
Schweiz. med. Wchnschr. 65: 724 (Aug. 10) 
1935. 

3. Heald. C. B.: Cod Liver Oil Treatment of 
Wound, Lancet. 2: 946 (Oct. 17) 1936. 



February, 1940 



COD LIVER OIL TREATMENT— HARDIN 



83 



with considerable success at the Royal Free 
Hospital. Between 1925 and 1929 a cod liver 
oil ointment called "Desitin-salbe" was used 
and recommended by Welkenbach*", Lauer- 
bach*''', Plankensteiner'"*, Glasenwald*'* and 
others in Germany. But the practical de- 
velopment and widespread acceptance of 
modern cod liver oil wound therapy origi- 
nated in the work of William Lohr of Magde- 
burg. In December, 1932, Lohr<»' first re- 
ported his astonishing success in the treat- 
ment of burns, ulcers, abscess cavities, os- 
teomyelitis, infected wounds, and various 
pyogenic skin infections with an ointment 
composed of crude cod liver oil and petro- 
latum (Unguentolan) and with plaster of 
Paris bandages. 

Bactericidal Properties of Cod 
Liver Oil 

That many fats have high antiseptic power 
which is directly proportional to their un- 
saturated fatty acid content has long been 
known. Cod and halibut liver oils are large- 
ly composed of unsaturated fatty acids, and 
rank among the best antiseptics. Lohr^''' 
found that cod liver oil is sterile, and that 
staphylococci, streptococci, and B. coli are 
destroyed by cod liver oil in four days. Even 
tubercle bacilli are readily killed by the oil. 
Tumanskiy and Jacevitch*'"' later showed 
that the growth of streptococci in sterilized 
and non-sterilized cod liver oil ceases in one 
hour and that staphylococci stop growing in 
six hours, whereas these same organisms 
grow for fifteen days in sterile petrolatum 
alone. 

4. Welkenbach (Magdeburg): Desitin Ointment 
for Wounds, Deutsche med. Wchnsehr. 51; 
1200 (July 17) 1925. 

5. Lauerbach, F.: Desitin Ointment in Treat- 
ment of Ulcers of Legs, Klin. Wchnsehr. 
4: 2478 (Dec. 17) 1925. 

6. Plankensteiner, R.; Uber eine Lebertansalbe 
(Desitin salbe) zur Wundebehandlung in der 
Geburtshilfe und Gynakologie, Wien. med. 
Wchnsehr. 77: 885 (June 25) 1927. 

7. Glasenwald, H.: Beobachtungen uber Wirk- 
.samkeit der Desitin-salbe, Prakt. Arzt. 14: 
278 (July 5) 1929. 

8. Lohr, W,, cited by Driver, Binkley, and Sul- 
livan: Urol, and Cutan. Rev. 42:587 (Aug.) 
19.38. 

9. Lohr, W., and Treusch, K.: Effect of Cod 
Liver Oil Salve on Pyogenic Bacteria, Zen- 
tralbl. f. Chir. (il: 1807 (Aug. 4) 19.34; 
abstracted, J. A.M. A. 10:3: 955, 1934. 

10. Tumanskiy, V. K., and Jacevich, I. A.: Treat- 
ment of Infected Wounds' with Cod Liver Oil 
(Russian), Klin. Med. 13; 1528 (Oct.) 1935; 
abstracted, J. A.M. A. 106: 259, 1936. 



Cod Liver Oil Treatment of Burns 

In numerous papers Lohr<'i-=i' has re- 
corded remarkable results in the cod liver 
oil-plaster cast treatment of several thou- 
sand cases of burns and assorted wounds. In 
nearly a thousand cases of extensive first, 
second, and third degree burns he reports a 
mortality of only 8 per cent. 

Lohr found that cod liver oil did not in- 
fluence the primary shock, but was unusually 
effective in controlling secondary infection. 
In fresh burns very little debridement is 
done. A thick layer of ointment is spread 
on the burned area, and the part is immedi- 
ately encased in a light plaster cast which 
is usually not removed for fourteen days. 
The ointment melts and the oil thoroughly 
permeates all necrotic tissues. The toxicity 
of the organisms is greatly reduced, if not 
entirely destroyed by the oil. At first there 
is tremendous activity with massive secre- 
tion of pus, which soon leads to separation 
of all necrotic material. Early demarcation 
occurs between the dead tissue and the 

11. Lohr, W.: Die Behandlung von fris'chen und 
alteren Hand-und Fussverlatzungen mit Sub- 
stanzverlusten mit dem Lebertran-Gipsver- 
band, Chirurg. 6:5 (Jan. 1) 1934. 

12. Lohr, W. : Die Behandlung grosser, flachen- 
hafter Verbrennungen 1, 2, und 3 Grades mit 
Lebertran, Chirurg. 6; 263 (April 1) 1934; 
abstracted, J. A.M. A. 102: 1991, 1934. 

13. Lohr, W.: Der Lebertran bei der ausseren 
Behandlung von Wunden, Deutsche med. 
Wchnsehr. 60: 561 (April 13) 1934. 

14. Lohr, W.: Cod Liver Oil Salve Treatment of 
Fresh Wounds, Burns, and Phlegmonous 
Wounds, Zentralbl. f. Chir. 61: 1686 (July 21) 
1934; abstracted, J.A.M.A. 103: 954, 1934. 

15. Lohr, W.: Cod Liver Oil and Plaster of Paris 
Casts in Poorly Healing Ulcerated Stumps 
with Large Tissue Defects Due to Charring, 
Freezing, or Amputation, Zentralbl. f. Chir. 
61: 1815 (Aug. 4) 1934; abstrated, J.A.M.A. 
103: 955, 1934. 

16. Lohr, W.: The Treatment of Fresh Injuries, 
Burns, and Phlegmonous Inflammations with 
Cod Liver Oil Salve With and Without Plaster, 
Tag. d. deutsch. Ges. f. Chir. 58, 1934. 

17. Lohr, W.: Treatment of Obstinate Wounds 
with Cod Liver Oil, Therap. d. Gegenw. 75: 
444, 1934. 

18. Lohr, W., cited by Holmes: Indust. Med. 6; 
77 (Feb.) 1937. 

19. Lohi", W.; Die Behandling der akuten und 
chronischen Osteomyelitischer Rohrenknochen 
mit Lebertrangips, Arch. f. klin. Chir. 180: 
206, 1934. 

20. Lohr, W.: Schweiz. med. Wchnsehr. 65: 927, 
1935; abstracted, Internat. Surg. Dig. 20: 323, 
1935. 

21. Lohr, W.; Treatment of Acute and Chronic 
Osteomyelitis of Tubular Bones by Means of 
Cod Liver Oil and Plaster Cast, Deutsche 
med. Wchnsehr. 62: 997, 1930; abstracted, 
J.A.M.A. 107; 833, 1936. 



8-1 



NORTH CAROLINA MEDICAL JOURNAL 



February. 1940 



healthy fresh granulations, which develop 
underneath with surprising rapidity. Areas 
still unhealed after removal of the plaster 
are treated with cod liver oil salve and 
bandaged. Large third degree burns are 
first treated with the ointment spread on 
sterile towels, and the application of the cast 
is delayed until secretion has lessened. Ex- 
tensive ulcerating third degree burns often 
heal in fourteen days, healthy granulation 
and epithelization advancing rapidly. The 
ointment and plaster treatment is equally 
applicable to old, dirty, chronically infected 
ulcerating burned areas. In 122 cases of 
severe second and third degree burns thus 
treated no skin grafting was required ; and 
Lohr did not once resort to skin grafting in 
the cod liver oil treatment of burns over a 
three and a half year period. In reference 
to this Lancef-"^ comments r "One doubts 
whether such success has attended any other 
method." 

Cod Liver Oil Treatment of Wounds 

Lohr's brilliant success in the cod liver oil 
ointment-plaster cast treatment of clean and 
infected wounds of the most varied types is 
due not only to the antiseptic properties of 
the oil, but primarily to its stimulating effect 
on granulation and epithelization resulting 
in a remarkable regeneration of all sorts of 
tissue defects. By the use of cod liver oil 
and rest he substitutes tissue regeneration 
for extensive debridements and reconstruc- 
tive plastic operations. 

The method is especially applicable to ex- 
tensive crushing injuries — where more 
tissue can be preserved — and to compound 
fractures, gunshot wounds, war wounds, 
postoperative wound cavities such as result 
from wide excision of malignancies, and to 
any injury where there remains an exten- 
sive tissue defect which had best not be 
closed by primary suture. In such cases, 
after the usual soap and water cleansing 
with a minimum of debridement, the wound 
is left unsutured, filled with the ointment, 
and dressed infrequently. Whenever practic- 
able a cast is applied which is not removed 
for two weeks, after which time the wound 
is generally found healed. 

This treatment is not applicable to acute 
inflammatory lesions, or to badly soiled 
wounds or gas bacillus infections. Here the 

22. Annotations. The Cod Liver Oil Treatment 
of Wounds, Lancet, 2: 367 (Aug. 18) 1934. 



usual measures of drainage, excision, sul- 
fanilamide, and application of disinfecting 
agents or hot moist dressings are first indi- 
cated to overcome the infection. After this 
preliminary treatment cod liver oil therapy 
is applied to the wound or abscess cavity as 
in clean wounds. 

Abscess cavities, amputation stumps, in- 
fected postoperative and other deep open 
wounds fill more quickly with granulations, 
epithelize more satisfactorily, and heal more 
rapidly with cod liver oil therapy than with 
any other method. In no type of wound is 
this excellent agent more widely useful than 
in the treatment of chronic, sluggish, non- 
progressive wounds such as ulcerations from 
burns or other causes, varico.se ulcers, and 
bedsores. Within a few days pale, station- 
ary, discharging, infected granulations may 
be tran.sformed into clean, fresh, healthy, 
activity and grow with unusual rapidity. 

Of course syphilis, diabetes, circulatory 
disease, erysipelas, cellulitis and lymphangi- 
tis, as well as pyocyaneous and gas infection 
must be adequately treated before local cod 
liver oil therapy can be effective. Anemia 
must be corrected, and consideration must 
be given to all measures for improving the 
patient's general condition if best results are 
to be secured. 

Possible Role of Vitamins 

The beneficial effect of cod liver oil or 
other vitamin ointments applied locally is 
attributed by most investigators to their 
vitamin A and D content. It is well known 
that vitamin A administered orally exerts a 
protective and regenerative influence on epi- 
thelium, especially on mucous membranes. 
But little is known about the actual relation- 
ship of vitamins to the therapeutic action of 
cod liver oil used locally. It is tempting to 
accept the hypothesis that the results are due 
to vitamin A contained in the oil, but it is 
not yet evident what part the vitamin plays. 

Types of Cases Treated in Present Series 

Our series of 84 wounds and burns treated 
with cod liver oil comprises the following 
types of cases: 

21 amputation stump.-;: 1 femur, 3 tibia and fibula, 
2 humerus. 1 radius and ulna. 4 metacarpal or meta- 
tars'al, 10 phalanx. 

6 compound fractures; metacarpal, metatarsal, or 
phalanx. 

1 severe multiple compound fracture skull. 

9 primary major bums: second or third degree. 



February, 1040 



COD LIVER OIL TREATMENT— HARDIN 



85 



6 very large ulcerating areas: 3 old burns, 2 
chronic undermining ulcers, 1 pressure sore under 
cast. 

8 deep wounds: penetrating-, gunshot, postopera- 
tive, or abscess cavity. 

1 acute osteomyelit's tibia. 

3 chronic osteomyelitis; 1 metatarsal, 2 phalanx. 

2 postoperative infected pilonidal cyst cavities. 

3 varicose ulcers, chronic. 

1 severe avulsion entire skin of penis. (To be 
reported). 

1 carbuncle wound following circular excision. 

22 assorted clean and infected open wounds and 
abscesses. 

Practical Considerations 

Cod liver oil is most curative when applied 
alone, but must usually be combined with 
petrolatum to form an ointment which has 
more body. After various trials we have 
found the combination of 50-70 per cent cod 
liver oil in autoclaved petrolatum to be most 
universally effective. The oil itself should 
not be sterilized, since this destroys the vita- 
mins. It should be very thoroughly mixed 
with the vaseline. In this study pure com- 
mercial cod liver oil has been used. This is 
produced by chilling out the stearin and cer- 
tain other fats from the crude oil, and filter- 
ing. The commercial product varies in vita- 
min A content from 400 to 2100 units per cc. 
For best results the higher vitamin content 
oils should be employed. Crude cod liver oil 
is the non-desterinated oil obtained from 
fresh cod livers. It is not readily available, 
but better results have been reported with 
crude oil than with the more commonly 
known pure commercial product. In the 
present series plaster of Paris casts have 
not generally been employed. Lohr empha- 
sizes the importance of such plaster band- 
ages, and in the future we plan to use them 
more often. 

Cn.se Reports 

Case 1. L. 0. K., a 49 year old refinery foreman 
critically burned over approximately 41 per cent of 
the body(-'3) when a blow torch ignited his clothing 
on September 30, 1935, was seen immediately after 
the accident; and for a time did well under tannic 
acid treatment. Before the end of the third week 
the coagulum separated from the second and third 
degree burns of the entire face and neck, both arms 
and hands, medial left buttock, thigh and leg, and 
entire perineum. These eventually healed with little 
infection but with considerable scarring. Because 
the coagulum remained dens'ely adherent, it was 
excised surgically from the entire lower right ex- 
tremity on the twentieth day. Figures 1 and 2 are 
photographs of this area taken the next day show- 
ing the entire limb except the upper anterior thigh, 

23. Berkow, S. G.: A Method of Estimating the 
Extensiveness of Serious Burns (and Scalds) 
Based on Surface Area Proportion, Arch. 
Surg. 8: 138, 1924, 



ankle and foot involved in a very deep fourth and 
fifth degree burn. The tendon of the biceps femoris 
is clearly exposed. 

Treatment of this extensive deep ulcerating area 
of approximately 3% square feet now presented a 
serious problem. Lack of facilities precluded the 
use of a continuous saline bath. Open air treat- 
ment under a lighted tent caused unbearable pain; 
and the agony accompanying boric ointment dress- 
ings for forty-eight hours indicated that some other 
therapy was imperative. The \vriter then tried cod 
liver oil for the first time in his experience. High 
vitamin commercial cod liver oil was mixed with 
.sterile petrolatum as a 50 per cent ointment and 
liberally applied to the wound on large gauze 
squares, and the entire limb was wrapped in sterile 
towels. Every eight hours cod liver oil was poured 
on the gauze, and the dressings were changed every 
forty-eight hours. 

The immediate relief from pain aflForded by this 
measure was striking. The oil s-aturated gauze never 
adhered to the wound, dressings were changed with- 
out pain, and the patient was comfortable and con- 
tented. In remarkably short time all sloughs sepa- 
rated; the wound was converted into a clean ruddy 
surface covered with healthy granulations, and was 
deemed ready for skin grafting nine days after cod 
liver oil therapy was started. The family delayed 
grafting for five weeks; but on the sixty-sixth day, 
using Blair's suction retractor and special graft- 
cutting knife<2'), ninety square inches of thick split 
skin grafts were taken from the patient's left thigh 
and applied to the medial and lower anterior right 
thigh, entire knee and popliteal space, and part of 
the medial and anterior leg. A 100 per cent suc- 
cessful "take" resulted. Cod liver oil therapy was 
continued meantime, and two and a half months 
later at a second operation eighty-seven square 
inches of thick split skin grafts were transferred 
to the right buttock, posterior thigh, and parts of 
the leg with a 95 per cent successful "take". 
Further surgery being refused, cod liver oil treat- 
ment was continued at home. 

The patient walked after eight months. Figures 
3, 4, 5, and 6 show him completely healed with ex- 
cellent function after nine months. He returned to 
his former occupation after ten months with a 5 per 
cent disability rating for slight heel cord shortening 
which soon disappeared under treatment. A recent 
letter states that he is in perfect health and work- 
ing. There is some occasional itching and discom- 
fort in the tannic acid scars, but no complaint from 
the right lower extremity treated with cod liver oil 
and skin grafting. 

Case 2. W. N. B., a married woman of 22, was 
seen in consultation with Dr. Oren Moore of Char- 
lotte to whom she had been referred nine months 
before; at that time she was seven months pregnant 
and was suffering from a severe chronic progressive 
undermining ulceration of the abdomen which had 
developed from a simple appendectomy performed 
elsewhere four months previously. When first seen 
by Dr. Moore she was delirious, a morphine addict, 
and a complete physical wreck. Following delivery 
by Dr. Moore she improved greatly, was cured of 
her morphinism, and after three weeks hospitaliza- 
tion went home with two special nurses. There the 
ulcer was treated with Dakin's solution and she 
gained 18 pounds, but returned after two months in 
much worse condition than before. 

She then showed an ulcer larger than a square 
foot in area involving the ventral wall of most of 
the lower abdomen with deeply undermined suppu- 

24. Blair, V. P. and Brown, J. B.: The Use and 
Uses of Large Split Skin Grafts of Inter- 
mediate Thickness, Surg., Gynec. and Obst. 
49: 82 (July) 1929. 



NORTH CAROLINA MEDICAL JOURNAL 



Februaiy. 1940 




Figs. 1 and 2. Appearance of right lower extremity 

24 hours after surgical excision of adherent 

tannic acid coagulum. 

Figs. 3 and 4. Final result at 9 months. Note in- 
creased scarring of lower leg which was not grafted 
compared to upper grafted areas. Compare with 
Fig. 1. 

rating edges and sinuses extending to the right flank 
and under the pubic bone. This large ulcer had de- 
stroyed all tissues down to muscle including the 
fascia, exposing most of the right iliac crest, and 
it was bathed in pus. Suffering agony, again an 
addict, and toxic with high septic fever, she was in 
a desperate condition. Repeated blood cultures were 
negative; wound cultures taken throughout her ill- 
ness always showed staphylococcus aureus; unfor- 
tunately anaerobic cultures were not obtained. Dia- 
betes and syphilis were ruled out. 

For two weeks the wound was dressed with bis- 
muth violet, but the ulceration progressed until Dr. 
Moore performed wide cautery excision of the en- 
tire diseased tissue. This .stopped the progress of 
the ulceration, but bismuth violet, Dakin's solution, 
saline and peroxide irrigations, staphylococcus vac- 
cine, and Thiersch grafting accomplis'hed practically 
no healing during the next five and a half months, 
and the wound edges again became deeply under- 
mined. Anorexia and anemia developed despite 
repeated blood transfusions, wound dressings cau.sed 
frightful pain, and her condition steadily deterio- 
rated. Figure 7 shows the ulceration soon after 
operation by Dr. Moore before, emaciation became 
marked. 

When the patient was first seen with Dr. Moore 



Fig. 3. Showing excellent functional result. Note 

absence of contracture about knee joint. 

Fig. 6. Note smooth healing of thick split skin 

grafts. Compare with Fig. 2. 

at the Presbyterian Hospital on February 25, 1938, 
thirteen months after the ulceration began, her 
weight had fallen from 135 to approximately 70 
pounds, severe flexion contractures of knees and 
thighs were present, her morale was utterly shat- 
tered, and the wound appeared only a little smaller 
than in Figure 7. Although the outlook appeared 
hopeless, cod liver oil therapy was advised. An 
ointment of 50 per cent commercial oil in vaseline 
was spread on gauze and applied locally. Every 
twelve hours cod liver oil was poured on, and dress- 
ings were changed every two days. The result was 
miraculous. Within thirty-six hours she became 
comfortable and slept without pain for the first 
time in months. On the eleventh day she was up in 
a chair after three months in bed. Almost over- 
night the wound took on new activity and soon was 
covered with fresh, clean, healthy, red granulations. 
Large areas filled in. Within a month the size of 
the ulcer was reduced more than 40 per cent, its 
area being now about 70 square inches (Fig. 8). 

Five weeks after starting cod liver oil treatment, 
under cyclopropane, the entire area was grafted 
with thick split skin grafts, after excision of the 
granulations and cutting away overhanging edges 
over the pubis. The graft covered about 72 square 
inches. The wound had been further prepared by 
continuous saline packs for the previous forty-eight 
hours and was apparently perfectly clean. But 
probably because of persisting infection under the 



February, 1940 



COD LI\"ER OIL TREATMENT— HARDIN 



87 




Fig. 7. Appearance of abdomen 10 months after 

ulceration began and 1 month after wide cautery 

excision of necrotic suppurating undermining 

wound edges. 

Fig. 8. Result of one month's treatment with cod 
liver oil ointment. Compare with Fig. 7. 

pubis and because of movement of the abdomen, 
the graft became infected, and only a 15 per cent 
"take" resulted. However, from scattered areas of 
viable graft epithelization proceeded under cod liver 
oil treatment, so that soon a third of the wound was 
healed. Subsequent grafting by Drs. Moore and 
J. Stuart Gaul and the constant u.se of cod liver oil 
completed the epithelization. and seven and a half 
months after cod liver oil therapy was begun the 
twenty-months-old wound was completely healed. 
No photographs were obtained. 

Unfortunately, however, some of the donor sites 
on the thighs cut too deeply at the grafting opera- 
tion became infected with the original ulcerative 
organism. In spite of many types of treatment 
these progressively ulcerated until one thigh was 
honeycombed with deep necrosing ulcers, which in 
places burrowed to the femur. In these cod liver 
oil was without effect. Because of flexion contrac- 
tures they could not be kept free of discharge and 
continued to burrow hopelessly. For many months 
the patient's general condition improved, but she 
suddenly developed lobar pneumonia and died nine 
months after cod liver nil therapy was instituted. 
This tragic case was seen by many consultants. AH 
agreed that the action of cod liver oil on the ulcer- 
ating abdomen was strikingly beneficial. 

Case 3. P. A., a 34 year old laborer was referred 
by Dr. J. J. Goudelock for appendectomy February 
16, 1938. The McBurney incision required upward 



enlargement for removal of an immovable deeply 
placed retrocecal subacute appendix reaching to the 
liver. Operation was difficult and heavy traction 
necessary. Post-operative ileus with serious vomit- 
ing almost proved fatal, and, together with severe 
distention, caused the wound to break down. By 
the twelfth day grave infection had completely rup- 
tured the wound and destroyed the entire belly wall 
over an area 4V2x2'/2 inches in size, within which the 
the intestines, covered with exudate, lay free. Simul- 
taneously a larger necrosing area of cellulitis de- 
veloped posterolaterally in the right flank. With 
alarming rapidity all soft tissues between the two 
wounds were destroyed down to the fascia by a 
•"regressive undermining ulceration which spread 4 
inches under the skin deep into the right flank. 
Here a counter incision was made for drainage, and 
on the sixteenth day all wounds, including the naked 
intestines, were dressed with 50 per cent cod liver 
oil-petrolatum ointment on gauze. 

Progressive ulceration stopped immediately, infec- 
tion rapidly subsided, and excellent healing began. 
On the fortieth day the patient was discharged, and 
at home healing was completed under cod liver oil 
therapy within three weeks. (Fig. 9.) 

Some months later the extensive ventral hernia 
was suecos.sfully repaired, using Babcock's rustless 
steel wire throughout. The scar was found widely 
adherent to the underlying intestines. Figure 10 
illustrates the final appearance of the wound twenty 
days after herniorrhaphy. The patient is now in 
good health and doing manual labor. 




Fig. 9. Showing excellent healing B^^i weeks after 

beginning treatment with cod liver oil ointment. 

Note large postoperative ventral hernia. See also 

counter incision in right flank indicating 

extent of the ulceration. 

Fig. 10. Final appearance after successful repair 
of large ventral hernia. 

Case 4. C. D., a 20 year old bride, alighting 
from an airplane was struck twice on the head by 
the revolving propeller blades, and sustained two 
severe compound fractures of the right parietal- 
frontal skull, with lo-ss of at least 2 ounces of brain 
substance. Desperate emergency treatment by Dr. 
J. J. Goudelock prevented death from hemorrhage 
and shock. When seen after twenty-four hours she 
was unconscious, and the wound had merely been 
covered with sterile gauze with no attempt at any 
cleansing, debridement, or closure. The approxi- 
mate appearance of the wound is shovni by Figure 
11, which is an artist's drawing from description. 
The right wound was about 6Vi inches long, extend- 



88 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 




Fig. 11. Artist's drawing from description demon- 
strating very severe compound fractures of skull 
caused by two blows of an airplane propeller. Note 
downward dislocation of right orbit and of large 
bone fragment which was freely movable between 
the two fracture clefts. 

ing from right parietal skull down through the orbit, 
malar bone, and cheek. The right eyeball was rup- 
tured posteriorly and the orbit displaced downward. 
The second was 4*2 inches long and parallel to the 
first, extending from about the mid frontal skull 
through the inner canthus. These two clefts of the 
skull were each 1 cm. wide and 2 inches apart. At 
least 2 ounces of lacerated brain tissue was extruded, 
and the bone flap between the fracture clefts was 
loose and movable. The left eye was normal, the 
pupil was contracted but reacted to light, the knee 
jerks were hyper-active, there were no abnormal 
toe signs, and no apparent paralysis. 

She was seen by Drs. Goudelock, James Gibbon. 
F. C. Smith, G. M. Smith. K. E. Neese, and myself. 
All agreed that they had never seen so extensive 
a cranial injury and that inevitably death would 
soon occur. It was further agreed that any im- 
mediate cleansing, debridement, or closure was con- 
tra-indicated. The usual general measures were 
pursued, and the wound was simply dressed with 
wet saline gauze and bandaged. 

On the third day. at my suggestion, pure com- 
mercial cod liver oil was used to saturate gauze 
which was applied directly to the lacerated brain 
substance and tn the entire wound. The dressing 
was changed daily. Under this treatment the patient 
improved against all expectation. In spite of some 
neck stiffness and fever of 100-10.3 degrees her con- 
dition improved. By the third week she took nourish- 



ment, regained sufficient consciousness to under- 
stand speech and obey commands, and even wrote 
legible notes to her husband, but never spoke a 
word. The wounds remained at all times relatively 
clean; there was no gross infection. The extruded 
brain soon separated; by the third week healthy 
granulations were filling the defects in skull, scalp, 
and cheek — the latter being closed by three sutures 
— and the discharge was moderate. On one occasion 
wet saline dressings were substituted for cod liver 
oil for four days, whereupon the temperature rose 
promptly to 105 degrees with a pulse of 150, and 
she rapidly grew worse. Improvement soon followed 
reestablishment of cod liver oil therapy. 

The wound continued to improve, but after the 
fourth week a fistula began to discharge clear spinal 
fluid, apparently from the right ventricle. She be- 
came increasingly comatose, developed left-sided 
tremors and weakness, and became emaciated. Al- 
though the condition of the wound continued to im- 
prove, the fistula eventually closed, and she died 
on the fifty-first day. apparently from the resulting 
increased intracranial pressure. 

This is the first case reported in this country in 
which cod liver oil has been used directly as a 
wound dressing for injured brain tissue or com- 
pound skull fracture. It was the consensus of 
opinion that this treatment reacted favorably upon 
the brain substance, hastened separation of lacerated 
extruded brain, greatly decreased infection, and 
rapidly accomplished satisfactory wound healing, 
and that death ultimately occuiTed after seven weeks 
from a low grade encephalitis and increased intra- 
cranial pressure. The method is recommended in 
other cases where attempted wound closure would 
certainly precipitate death. 

C^se 5. J. S.. a 62 year old farmer, was iTished 
to the hospital June 8. 1938. immediately after his 
gloved right hand had been mangled in a threshing 
machine. There were multiple compound commi- 
nuted fractures of thumb, all fingers, and three 
metacarpals (Figs. 13 and 14.) The thumb was 
nearly severed by multiple lacerations. There was 
complete avulsion of the index and middle fingers, 
which hung only by shreds and were not viable. 
The fourth and fifth fingers were very gravely 
lacerated, while all soft tissues of the dorsum had 
been torn from the hand with extensive tissue loss, 
division of all extensor tendons, and practically 
complete disintegration of the entire hand. 

After treatment of shock and administration of 
combined tetanus and gas gangrene antitoxin, the 
patient was etherized, the extremity thoroughly 
washed with soap and sterile water, and extensive 
plastic repair accomplished, especial attention being 
devoted to minimal debridement and careful pres- 
ervation of all viable tissues. After completing the 
amputation of the index and middle fingers, all com- 
minuted compound fractures of thumb and fingers 
were reduced, surviving tendons sutured with silk, 
dorsal soft tissues reestablished, index and middle 
metacarpal exposed ends covered with tissue, and 
appropriate drainage was nlaced under the dorsal 
flap. No skin sutures were used, and the injury 
was dressed with continuous warm saline gauze 
packs, and splinted. Fever of 102 degrees on the 
second day fell to normal on the fifth day; no in- 
fection occurred. 

On the fifth day the wound was liberally dressed 
with 50 per cent cod liver oil-va.seline ointment 
saturated gauze, and the patient discharged. The 
hand was dressed in the 0. P. D. for ten weeks, 
and healing was complete after several months. 
(Figs. 15, 16. and 17.) There is good motion of 
thumb and fifth finger, which can be approximated, 
giving a useful hand with which he is able to plow. 
Considering the gravity of the injury this is an ex- 



February, 1940 



COD LIVER OIL TREATMENT— HARDIN 
/3 



89 




Fig. 13. Showing extensive soft tissue destruction 
and practically complete disintegration of hand. 

Fig. 15. Final result 6 months after repair and 
treatment with cod liver oil ointment. Note cover- 
ing of dorsum of hand and of metacarpal ends. 
Compare with Figs. 12 and 13. 

cellent result, and must be attributed largely to 
cod liver oil. 

Case 6. Mrs. L. R., age 83, was referred on 
Januaiy 17, 1938, by Dr. C. A. Bolt of Marshville, 
fifteen days after sustaining severe second and third 
degree burns of approximately 17 per cent of the 
body when her gown ignited from the fii-eplace. 
The burns involved much of the posterior thighs 
and perineum, the entire buttocks, and most of the 
lumbar back. No debridement was done by Dr. 
Bolt, but cod liver oil gauze dressings were applied 
every forty-eight hours. On admission she appeared 
vigorous and had little pain; the burned areas were 
fairly clean and showed many islands of healthy 
granulation, but some crusting and discharge. 

She was placed on her abdomen under a buin 
tent and dressed ever.v two da.vs with .50 per cent 
cod liver oil-vaseline ointment on gauze. The daily 
temperature ranged from 97-100 degrees, falling to 
normal after the eighth day. Seven weeks after 
being burned she was up in a wheel chair, and went 



Fig. 14. Roentgenogram of hand. 

Fig. 16. Final appearance of palmar surfaces 
of hand. 

Fig. 17. Illustrating good functional result. There 
is good movement of thumb and fifth finger. Note 
ankylosis of fourth finger. Compare with Fig. 13. 

home healed after eight weeks. Figure 18 shows 
the burns" some days before discharge, and Figure 
19 reveals only moderate scarring after fourteen 
months. There is occasional discomfort in the right 
scars; but the progress and recovery of this severely 
burned 83-year-old woman under cod liver oil 
therapy was considered remarkable. 

Case 7. G. N., a 35 year old farmer with ar- 
rested pulmonary tuberculosis, received first degree 
burns of the face and severe second and third de- 
gree burns of the neck, shoulders, extensor surfaces 
of both arms and hands, both knees, and dorsum 
of both feet, involving about 16 per cent of the 
body surface, when exposed for about forty seconds 
to reflected heat under the roof of his burning barn 
on November 10, 1938. He was treated by Dr. K. 
E. Neese, who immediately applied 50 per cent cod 
liver oil-petrolatum ointment without debridement. 
When refen-ed by Dr. Neese twelve hours after the 
accident his Hgb. was 110, and all the burns, except 



90 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 




^ 






Fig. 18. (Case 6) .\ppearance of burn.s after 6 

weeks of cod liver oil treatment. Epithelization 

nearly complete. 

Figs. 20 and 21. (Case 7) Showing excellent heal- 
ing with minima) scarring 9 weeks after burn. 

the face were covered with large blisters from 
which he had already suffered considerable fluid 
loss. The vesicles were aseptically opened, dead 
skin was excised, and the areas were washed with 
boric solution. Cod liver oil salve on gauze was 
continued and changed every two days. Consider- 
able infection occurred and fever reached 102.8 de- 
grees, but fell to normal on the thirteenth day. 
Sloughs soon separated and granulation was rapid. 
He was discharged on the nineteenth day, and the 
few remaining deeply bui'ned areas on the right 
shoulder and forearm healed under bismuth violet 
by the twenty-fourth day. This patient's burns 
healed very rapidly in spite of infection. Figures 
20 and 21, taken after nine weeks, show minimal 
scarring. Four months later, however, s'cvere keloids 
had foiTiied over the right shoulder and forearm. 

Ca.se S. E. Y., a 20 year old negro farmer, rolled 
into the fireplace while intoxicated and sustained 
severe first, second, and third degree burns of the 
left hand, wi-ist. foi-earm. and most of the left 
abdomen — altogether about 12 per cent of the body. 
Dr. J. W. Ormand opened all blisters, removed the 
burned skin, and applied iiO per cent cod liver oil- 
petrolatum ointment covered with waxed paper. 



Fig. 19. (Case fi) Final appearance 11 months after 

burn. Note slight scarring and absence of keloid. 

Compare with Fig. 18. 

Fig. 22. (Case 8) .Vppearance after 4 months. 

showing very little scarring considering depth 

and extent of the burn. 

Some infection developed after the fifth day, but 
was controlled by wet magnesium sulphate dress- 
ings for forty-eight hours, and the bums healed 
well. He was discharged after six w-eeks and was 
entirely healed in seven weeks. Figure 22 shows 
the excellent final result photographed after four 
months. 

Comment 

In the limited time available it is impo.'?- 
.sible to discuss the admirable results secured 
with cod liver oil in practically all of the 84 
cases on which this study is based. But it 
is hoped that these few representative cases 
presented in detail have demonstrated many 
of the advantages of the cod liver oil method. 
Suffice it to state that our experience in this 
series strongly confirms the majority of the 
claims made by other investigators. 

Of course cod liver oil ointment is no 



February, 1940 



COD LIVER OIL TREATMENT— HARDIN 



91 



panacea for all the evils encountered in the 
process of wound healing. In certain rare 
instances the method may prove ineffective. 
Exuberant granulations at times require 
trimming and the application of silver ni- 
trate. Occasionally it is best to change to 
bismuth violet or Bettman's<"> oxyquinoline 
scarlet R. ointment, or to use hot wet saline, 
boric, or magnesium sulphate dressings for 
a while. Whenever indicated, skin grafting 
should be employed without delay. 

The disadvantages are few and relatively 
unimportant. In treating extensive burns 
or ulcerations large amounts of the ointment 
are needed, and the expense is considerable. 
But, as Lohr points out, the additional cost 
is more than compen.sated by the patient's 
more rapid healing and return to health. In 
our experience the disagreeable odor of fish 
oil, though occasionally objectionable, has 
not proved seriously unpleasant to the 
patient. This is easily controlled by sprink- 
ling a few drops of turpentine on the dress- 
ings. Rancidity seldom occurs, since the 
ointment is self-sterilizing and keeps indefi- 
nitely in dark containers; and even rancid 
oil does not harm the wound. No ill effects 
have been reported from hyper-vitaminosis. 
Irritation and maceration of the skin do not 
occur. 

Summary and Conclusions 

1. Results with this method are described 
in case reports, including the first record of 
the use of cod liver oil on the naked brain 
in this country, the first cui'e of chronic pro- 
gressive undermining ulcer of the abdomen 
with cod liver oil to be reported, and the 
first successful application of cod liver oil 
ointment to the intestines to appear in the 
literature. 

2. From a study of 84 cases consisting of 
75 assorted clean and infected wounds and 
9 fresh major burns treated by the writer 
and other members of The Ellen Fitzgerald 
Hospital staff it is concluded that as a rule 
more tissue is saved, infection is better con- 
trolled, tissue regeneration is more acceler- 
ated, less scarring occurs, pain is more com- 
pletely eliminated, hospitalization is shorter, 
and a better final functional result is 
achieved by the use of cod liver oil-petrola- 
tum ointment than with other methods of 
therapy. 

25. Bettman, A. G.: A Simpler Technie for Pro- 
moting Epithelization and Protecting- Skin 
Grafts, J.A.M.A. 97: 1879 (Dec. 19) 1931. 



3. These conclusions apply especially to 
the treatment of wounds, in which, the au- 
thor's observations have fully convinced him 
that cod liver oil offers a superlative method 
of therapy universally applicable to the 
treatment of wounds of practically every 
variety. 

4. During the three and a half years in 
which this method has been employed by the 
writer, in no single case has it been necessary 
to use Dakin's solution on any wound — cod 
liver oil ointment combined with the judi- 
cious use of hot saline applications having 
displaced this procedure. 

5. It is emphasized that external cod liver 
oil therapy is contra-indicated in the pres- 
ence of acute infection. Its employment in 
the hope of combating such infection is con- 
demned. Only after active infection has 
been controlled by means of all commonly 
accepted surgical measures will cod liver oil 
be effective. 

6. Our small series of 9 cases in which 
cod liver oil ointment was used as a primary 
dressing for fresh major burns does not 
warrant final conclusions, but the writer be- 
lieves the method ideal in the treatment of 
burns of the face, perineum, extremities, and 
places where body surfaces come in contact. 
In other fresh burns Bettman's*-"' tannic 
acid-silver nitrate method is preferred. In 
old ulcerating burns the oil is without a peer. 

Discussion 

DR. RANDOLPH JONES, JR. (Durham): I want 
to congratulate Dr. Hardin on this really amazing 
group of cases which he ha.s shown us here. 

We have been using cod liver oil since 1933. I 
am sure all of you have noticed the striking free- 
dom from pain that follows its application. 

I remember one case that came to my care. Some 
students during initiation had smeared a boy liber- 
ally with collodion, and while he was sitting in front 
of an open fire he was painfully burned. The relief 
he experienced following the application of cod liver 
oil was dramatic. 

I think Dr. Hardin is to be congratulated on the 
results he has obtained. 

DR. C. L. HAYWOOD, JR. (Elkin): Mr. Chair- 
man, I have had a very limited experience with the 
use of cod liver oil. I have used it as a 50 per 
cent mixture with linseed oil to help clean up granu- 
lations and promote epidermization. 

I have had my best luck with it in closing para- 
nasal sinuses. Sometimes they are very slow to 
granulate and heal. While this is usually a minor 
operation with little danger to the patient, it is a 
dis-tressing thing to have to go with a granulating 
wound for such a long time. Cod liver oil is an 
excellent method for promoting a rapid and clean 
closure of the sinuses. 

26. Bettman, A. G.: The Tannic Acid-Silver Ni- 
trate Treatment of Burns, Northwest. Med., 
34: 46 (Feb.) 1935. 



NORTH CAROLINA MEDICAL JOURNAL 



February. 1940 



MALARIA STUDIES AND IX^T:STIGA- 
TIONS IX NORTH CAROLINA 

bv 

C. M. White, Engineer, 

Malaria Investigation and Control Unit 

North Carolina State Board of Health, 

Raleigh 

and 

L. L. Parks, :\I.D., District Health Officer 

Tarboro 

Introduction 

In 1933 the State Board of Health, co- 
operating with the U. S. Public Health Ser- 
vice, began the most extensive malaria con- 
trol program ever undertaken in North Car- 
olina. The Ci\-il Works Administration was 
willing to furnish labor, materials, and 
equipment for the eradication of any mos- 
quito breeding areas which we designated as 
menaces to the public health. Due to lack of 
previous malarial studies the endemic areas, 
with the exception of those established mere- 
ly by reputation, were unknown. 

Entomological investigations had been 
limited to scattered areas, and engineering 
personnel with specialized training in ma- 
laria control was not available for the super- 
\-ision of a program of this magnitude. As a 
result, the program was largely conducted 
on the hj-pothesis that all bodies of fresh 
water breed anopheles mosquitoes and 
should be drained if the population in the 
vicinity were large enough to justify the cost. 
No apology is made for this procedure. We 
did the best that we could under the circum- 
stances. The subsequent decline in malaria 
in numerous localities where projects were 
carried through to completion shows that 
enormous benefits were derived. Had we 
known the location of malaria foci and 
sources of anopheline breeding, projects 
would have been selected in areas where the 
most good could be accomplished and the re- 
sulting benefits would have been more than 
doubled. This experience disclosed the neces- 
sity for a more thorough knowledge of the 
location and extent of malaria within the 
state. 

Malaria Investigation and Control Unit 

Conforming with the recommendation of 
the United States Public Health Service that 
each state which had a malaria problem in- 
Read before Uie Section on Public Health and Education. 
Medical Society of lie State of Sorth Carolina. Bermuda 
Cruise. Mar IC 1889- 



stall a special investigation and control unit, 
the North Carolina State Board of Health 
in 1937 set up such a unit under the direc- 
tion of Dr. J. C. Knox, Director of the Di- 
vision of Epidemiologj-. Its main purpose is 
to develop the scientific understanding and 
control of malaria in North Carolina on a 
count>--wide basis, in collaboration with the 
local health departments. In addition to 
Doctor Kno.x, the unit has one engineer, one 
entomologist and two laboratory technicians, 
all of whom have had specialized training in 
Malariologj-. 

Before a detailed malaria survey is begun 
in a countj-, the local health officer agrees to 
allow his personnel to take blood slides from 
all school children through the first six 
grades. After the slides are examined the 
precise location of the home of each child 
with a positive slide is established with a 
sjTnbol on a large count\- map. The densitj' 
of these sj-mbols shows the foci. 

In areas thus shown to be highly malarious 
detailed malariological studies are made, 
which include: 

1. A spot map showing: all cases of ma- 
laria disclosed by house to house interviews 
and verified by the family doctor; all posi- 
tive bloods ; all water and water courses 
within one mile of the area ; and all areas 
found to be breeding Anopheles quadrimacu- 
latus mosquitoes. 

2. A study of the breeding habits and 
distribution of the local vector. 

3. A determination and cost estimate of 
the most effective and feasible methods of 
control. 

Due to the limited facilities and amount of 
detailed work involved, it is impossible to 
make detailed surveys in more than two or 
three counties each year. Surveys are made 
in counties other than those participating in 
the program in the small areas where se- 
rious malaria problems are known to exist. 

Survey Results 

In selecting counties to be covered by de- 
tailed surveys it was desired that the most 
malarious counties be taken first. The deter- 
mination of which counties had the most 
malaria presented a difficult task, as mor- 
bidity reports were not required on malaria 
prior to May, 1937. This made it necessary 
to rely entirely on mortality statistics. In 
compiling the deaths from malaria over a 
five-year period it was found that Robeson 



February, 1940 



MALARIA STUDIES— WHITE AND PARKS 



93 



County led the State with thirty, while 
Edgecombe County was a close second with 
twenty-nine, with Beaufort, Pitt and Wayne 
Counties following in the order named. 

In the fall and winter of 1937, 4,629 blood 
slides were taken from school children in 
Edgecombe County and 4,932 from those in 
Robeson County. Not all of the schools were 
taken in either of these counties, as work 
was discontinued because of the lateness of 
the season. Previous experience had shown 
that a true index could not be obtained at 
any season other than the fall of the year. 

Positive results ranged from none, in some 
schools, to 62 per cent at Harper's Ferry 
Indian School in Robeson County. In Robe- 
son County 2.2 per cent of the slides taken 
were positive, while in Edgecombe County 
3.9 per cent were positive. In Robeson 
County the Negro schools were 2.4 per cent 
positive, the white schools 1.1 per cent posi- 
tive, and the Indian schools 5.5 per cent posi- 
tive. In Edgecombe County 5.9 per cent of 
tests from Negro schools were positive, and 
from white schools 1.3 per cent. 

A recapitulation of results from the two 
counties shows that of 5,586 slides taken 
from white children 66, or 1.2 per cent, were 
positive ; of 2,893 taken from Negro children 
160, or 5.5 per cent, were positive; and of 
1,082 taken from Indian children 60, or 5.5 
per cent were positive. 

The theory that Negroes are more suscep- 
tible to estivo-autumnal and whites to vivax 
was strengthened by the findings of these 
surveys. Sixty-five per cent of the infected 
Negroes had estivo-autumnal, 29 per cent 
vivax, and 6 per cent showed mixed infec- 
tion. Among whites, 39 per cent had estivo- 
autumnal, 59 per cent vivax, and 2 per cent 
had mixed infections. Susceptibility among 
Indians conformed closely with that among 
whites. Twenty-three per cent of them had 
estivo-autumnal, 70 per cent vivax, and 7 
per cent mixed infections. 

The homes of all childi'en with positive 
slides have been located on county maps, 
and detailed investigations are completed or 
in progress in all endemic communities thus 
established. Spot maps showing actual pic- 
tures of the conditions as they exist have 
been instrumental in getting several large 
drainage projects started, and have been 
very helpful in persuading pond owners to 
apply voluntary control measures to im- 



pounded waters which were in existence 
prior to the adoption of the State Board of 
Health's regulations governing impounded 
waters. 

During October and November of 1938 the 
local health departments in Halifax, Wayne 
and Pitt Counties took blood slides from all 
school children in the first six grades, and 
the survey begun in Edgecombe County in 
1937 was completed. A total of over 22,000 
blood slides were taken. These have been 
stained and prepared for examination. It 
will take the two laboratory technicians all 
the year to examine them ; so results are not 
yet available. 

It is hoped that in counties where enough 
malaria is disclosed to justify it, funds will 
be provided by the local authorities for the 
establishment of permanent malaria control 
programs to be operated under the super- 
vision of the local health departments, co- 
operating with the State Board of Health. 

The interest of one of us (Parks), as local 
health officer, in the malaria problem dates 
back to 1936, when a malaria survey was 
made in Edgecombe County, in which 2703 
slides were examined. These slides were 
made by W. P. A. nurses and examined 
through the cooperation of the State Board 
of Health and the United States Public 
Health Service at Washington. 

The purpose of the survey then was (1) 
to determine the incidence of malaria in the 
county, (2) to find where W. P. A. drainage 
projects should be located, (3) to stimulate 
the interest of the public in our malaria 
problem, and (4) to serve as a public health 
investigation project and a record for future 
reference in malaria control problems. 

The survey that was done in 1936 in Edge- 
combe has been continued to date, and has 
accomplished more than we anticipated. 
From 1936 through 1938 approximately ten 
thousand slides have been made. 

The Edgecombe County officials have 
taken a great deal of interest in the malaria 
problem, and have given considerable finan- 
cial support. A drainage district has been 
formed which is now being dredged. This 
district, when completed, will improve our 
malaria situation and restore some good 
farm land that has been useless for the past 
several years because of floods. A number 
of small drainage projects have been com- 
pleted through the cooperation of the W.P.A. 
and individual land owners. The city of 



94 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



Tarboro has employed a full time mosquito 
inspector for the past two years during the 
mosquito season, and the results of his work 
has been gratifying. His services are also 
available this year. 

If we go into the malaria problem we find 
that malaria is a problem of the entire state, 
and not limited to Edgecombe County or the 
eastern part of the state. A map of North 
Carolina would show that malaria deaths 
were found in sixty-seven of the one hundred 
counties during the years 1934-1938. The 
number varies from one death in twelve 
counties to forty -one in Beaufort, thirty-five 
in Edgecombe, and three in Robeson County 
■ — an average of one death per county each 
year. Malaria deaths occur in all sections of 
the state. 

Malaria was made a reportable disease in 
this state in May, 1937. Since that time 
fifty-nine counties have reported this disease. 
We also know that the majority of cases are 
not reported by physicians, and that many 
cases of malaria are not attended by a phy- 
sician. 

Malaria is a health problem that many 
health departments have probably over- 
looked in our state. A report of the number 
of deaths attributed to malaria as compared 
with the number from dipththeria and ty- 
phoid fever is interesting: 







1937 




1938 






By Place of Residence 


By riace of Death 
(Proiisional) 


Disease 


Counties \\ 
Deaths 


ith 


No. of 
Deaths 


Counties With 
Deaths 


No. of 
Deaths 


Typhoid F. 
Diphtheria 
Malaria 


39 
73 
38 




75 

167 

90 


36 
60 
35 


70 

180 

78 



These figures show that malaria is one of 
our leading public health problems and that 
work must be done to combat it. 



The Doctor-Patient Relationship. — The profession- 
1 1 man is piimarily a learned man, a man who 
depends upon his knowledge as his stock in trade. 
He has specialized knowledge over and above that 
of the common man in relation to some particular 
topic, be that law, theology, accountancy, teaching, 
or medicine. Perhaps the thing that distinguishes 
him more than anything else is the peculiarly per- 
sonal relation to the client or patient which he 
enjoys, a confidential relationship, a situation in 
which he is adviser, guide and friend, a situation in 
which his interest does not cease when the particu- 
lar transaction is concluded. It follows as a corol- 
lary that he is an individualist, one who functions 
far more efficiently without regimentation or co- 
ercion, but rather requires the opportunity to utilize 
freely his own initiative and judgment within the 
limits of his professional code of ethics. — Winfred 
Overholser: The Broadening Horizons of Medicine, 
Science 90: 2338 (Oct. 20) 1939. 



LOW BACK PAIN AND SCIATICA WITH 

SPECIAL REFERENCE TO RUPTURE 

OF THE INTERVERTEBRAL DISC 

B.\RNES WOODHALL, M.D. 

R. Beverly Raney, M.D. 
W. W. Vaughan, M.D. 

Durham 

Low back pain as.sociated with pain radi- 
ating along the distribution of the sciatic 
nerve is a commonly observed clinical syn- 
drome following certain types of relatively 
minor injuries to the lumbar spine. Indeed, 
these disturbing complaints may develop 
without any clear history of antecedent 
trauma. Orthopedic surgeons have estab- 
lished a large number of entities which may 
produce these symptoms, embracing various 
possible lesions of low back structures. In 
this complex group are included as etiologi- 
cal factors : strains, of the lumbo-sacral and 
sacroiliac articulations; developmental ab- 
normalities at the lumbo-sacral junction; 
narrowing of the lumbo-sacral interspace ; 
spondylolithesis ; the facet syndrome ; arthri- 
tis ; myositis ; fascial contractures ; and pos- 
tural abnormalities. Orthopedic surgeons 
have devised certain therapeutic procedures 
to relieve such disturbances, ranging from 
conservative measures of bed rest, traction, 
supportive appliances, manipulation, and 
epidural injection to such radical measures 
as fasciotomy and fusion of the involved 
bony structures. Although no exact statis- 
tical figures are available, probably 90 per 
cent of individuals with low back pain, often 
associated with sciatica, may be considered 
essentially orthopedic problems in diagnosis 
and treatment. 

There remains, however, a numerically 
small group of individuals with the same 
complaints of low back pain and sciatica in 
whom these orthopedic disturbances cannot 
be demonstrated, and in whom the usual 
methods of treatment are ineffectual. This 
group includes those patients with actual 
compression of the roots of the cauda equina 
from a ruptured intervertebral disc, from a 
hypertrophy of the ligamentum flavum, from 
a tumor of the cauda equina, or from an 
arachnoiditis involving this region. It like- 

From the Departments of Surger>' and Roentgenology, Duke 
L'niversity School of Medicine and Hospital and the Walts 
Hospital. Durham, N. C. Read before the Section on Surgerj', 
Medical Society of the State of North Carolina, Bermuda 
Cruise, May 13. 1939. 



February, 1940 



LOW BACK PAIN— WOODHALL ET AL. 



95 



wise includes those patients with an intrinsic 
lesion of the cauda equina, such as radiculi- 
tis, caused by trauma, infection or a chemi- 
cal agent. Finally, it includes those patients 
who are malingerers or who have developed 
a traumatic psychosis with their somatic 
complaint referred to the lumbar spine. 

This paper will record our experience with 
39 patients in this latter group on whom 
lipiodol studies were done, and will discuss 
more explicitly 25 patients in whom the clini- 
cal syndrome of a ruptured intervertebral 
disc was recognized and treated. 

The historical development of this clinical 
picture is a record of repeated isolated ob- 
servations, from the first report of an injury 
to an intervertebral disc by Kocher"* in 1896, 
to the summation of this experience in the 
classical paper by Mixter and Barr<-' in 
1934. In 1911, Goldthwaite'-" first suggested 
that injuries to the intervertebral di.sc might 
be a cause of low back pain and sciatica. 
As neurosurgeons developed spinal cord 
surgery, there appeared in the literature 
many reports of the removal of enchon- 
dromata arising from the intervertebral disc 
— among them the papers of Adson'", 
Dandy<" and Elsberg<">. Noteworthy is 
Dandy's statement refuting the current con- 
ception of these tumors as true neoplasms, 
and suggesting rather their traumatic der- 
ivation. In 1932 and later, Schmorl*'' de- 
scribed degenerative changes in the annulus 
fibrosus of the disc with anterior, posterior 

1. Kocher, T.; Die Verletzungen der Wirbel- 
saule zugleieh als Beitrag zur Physiologie de.s 
menschlichen Ruckenmarks, Mitt. a. d. Grenz- 
geb. d. Med. u. Chir. 1: 415, 1896. 

2. Mixter, W. J. and Ban-, J. S.: Rupture of the 
Intervertebral Disc with Involvement of the 
Spinal Canal, New England J. Med. 211; 
210 (Aug. 2) 1934. 

3. Goldthwaite, J. E. : The Lumbosacral Articu- 
lation: An Explanation of Many Cases of 
"Lumbago", "Sciatica", and Paraplegia, Bus- 
ton M. and S. J. 164: 365, 1911. 

4. Adson, A. W. : Diagnosis and Treatment of 
Tumors of the Spinal Cord, Northwest Med. 
24: 309 (July) 1925. 

5. Dandy, W. E.: Loos'* Cartilage from Inter- 
vertebral Disc Simulating Tumor of the Spinal 
Cord, Arch. Surg. 19: 660 (Oct.) 1929. 

6. Elsberg, C. A.: The Extradural Ventral 
Chondromas (Ecchondroses), Their Favorite 
Sites, the Spinal Cord and Root Symptoms 
They Produce, and Their Surgical Treatment, 
Bull. Neurol. Inst. New York, 1: 350 (June) 
1931. 

7. Schmorl, G., and Junghanns, H.: Die ge.=;unde 
und kranke Wirbelsaule im Rontgenbild; 
Pathologisch-anatom ische Untersuchungen. 
Fortschr. a. d. Geb. d. Rontgenstrahlen, Er- 
ganzungsband XVIII.) Leipzig, Georg Thieme, 
1932. 



and intravertebral ruptures of the nucleus 
pulposus — observations that were shortly 
followed by the presentation of the complete 
clinical picture by Mixter and Barr. That 
the syndrome has a sound anatomic-patho- 
logic status has been amply demonstrated 
by Batts<*>, who has pointed out ruptures of 
the nucleus pulposus of varying degrees in 
18 per cent of 50 cadavers; and by Naff- 
ziger<" and his as.sociates, who have made 
detailed anatomical studies of the region in- 
volved in this syndrome. That it is of pro- 
found clinical importance may be judged by 
the succession of clinical and radiological re- 
ports that have appeared since 1934<"". 

CLINICAL DATA— 25 CASES 

Sex: 24 males; 1 female 

Age: average, 36; oldest, 53; youngest, 21 

History of Trauma: positive, 17; negative, 8 

Present Reported 
Symptoms Series Cases 

1. Average Duration 42 months 48 months 

2. Low Back Pain 25 cases 58',( 

3. Sciatica 25 92<A 

4. Intermittent Symptoms 24 86% 

5. Accentuated by Coughing, 

Etc. 9 39% 

6. Accentuated by Movement 23 — 

7. Paraesthesiae 12 49''i 

8. Weakness 9 

8. Batts, M. Jr.: Rupture of the Nucleus Pul- 
posus, J. Bone and Joint Surg. 21: 121 (Jan.) 
1939. 

9. NafTzinger, H. C, Inman, V., and Saunders, 
J. B. de C. M.: Lesions of Intervertebral 
Disk and Ligamenta Flava: Clinical and Ana- 
tomic Studies, Surg., Gvn. and Obstet. 66: 
288 (Feb.) 1938. 

10. a Mixter, W. J. and Ayer, J. B.: Hernia- 
ation or Rupture of the Intei-vertebral 
Disk into the Spinal Canal: Report of 
Thirty-Four Cases, New England J. Med. 
213: 385 (Aug. 29) 1935. 

b Hampton, A. O., and Robinson, J. M.: 
The Roentgenographic Demonstration of 
Rupture of the Intervertebral Disk into 
the Spinal Canal after the Injection of 
Lipiodol, with -Special Reference to Uni- 
lateral Lumbar Lesions Accompanied by 
Low Back Pain with "Sciatic" Radiation, 
Am. J. Roentgenol. 36: 782 (Dec.) 1936. 

c Barr, J. S.: "Sciatica" Caused by Inter- 
vertebral Disk Lesions, J. Bone & Joint 
Surg. 19: 323 (April) 1937. 

d Barr, J. S., Hampton, A. O., and Mixter, 
W. J.: Pain Low in the Back and 
"Sciatica", J. A. M. A. 109: 1265, (Oct. 
16) 1937. 

e Love, J. G., and Walsh. M. N.: Protruded 
Intervertebral Discs, J. A. M. A. 3: 396, 
(July 30) 1938. 

f Barr, J. S.: Relationship of Interverte- 
bral Disk to Back Strain and Peripheral 
Pain (Sciatica), Sui-gerv, 4: 1 (July) 
19.38. 

g Walsh, M. N., and Love. J. G.: The 
Syndrome of the Protruded Interverte- 
bral Disk. Proc. Staff Meet., Mayo Clin. 
14: 230 (April 12) 1939. 



96 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



82% 

57% 

26% 
31% 

57% 

10% 

10% 
Normal 



Objective Signs — Orthopedic 

1. Localized Tenderness 13 

2. Paravertebral Muscle 

Spasm 18 

3. Change in Lumbar 

Lordosis 10 

4. Restriction of Lumbar 

Flexion 19 

5. Scoliosis 9 

6. Positive Leg Raising Test 25 
Objective Signs — Neurologic 

1. Sciatic Tenderness 7 

2. Motor Wealiness and 

Atrophy 10 

3. Sensory Loss 17 

4. Reflex Changes 18 

5. Fibrillary Twitchings 2 

6. Negative Examination 2 
Examination of Spinal Fluid 

1. Positive Queckenstedt 

3. Cell Count Normal 

2. Reverse Queckenstedt — — 

4. Total Protein 

Not Done— 2 

Above Above 

80 mg./lOO cc— 12 40 mg./lOO cc— 80% 

Above Below 

40 mg./lOO cc— 11 40 mg./lOO cc— 20';i, 
Localization of Ruptured Disc 

Lumbar 111 3 lO'c 

Lumbar IV 12 40% 

Lumbar V 10 48% 

Above Lumbar III None 2% 

Twenty-four of the patients in this series 
were active, vigorous males, ranging in age 
from 21 to 53 years. In 17 of the patients, 
a definite history of trauma preceding the 
onset of symptoms was obtained. The re- 
mainder, it was noteworthy, volunteered the 
history of heavy physical labor as a part of 
their daily existence. The character of the 
inciting trauma was typically that obtained 
by forceful hyi)erextension of the lumbar 
spine, a movement frequently developed in 
the course of lifting a heavy weight. In- 
juries and positions that produce such hyper- 
extension exert a rending force upon the 
posterior longitudinal ligament, and by com- 
pression of the disc space anteriorly may 
rupture the nucleus into the dural canal. 
Such an acute accident may be precipitated 
by a simple trauma, and patients may be 
aware of a "snap", followed by immediate 
pain in the lumbo-sacral region. On the 
other hand, the low back pain may occur 
after one of repeated and comparatively 
mild traumatic insults to this area — evidence 
for the supposition advanced by Schmorl 
that degenerative changes of traumatic 
origin may take place in the posterior longi- 
tudinal ligament. 

The presenting symptom of low back pain, 
aching and throbbing in character, was pres- 
ent in all of the patients in this series. This 
pain may be quite mild and overshadowed 



by the severe, lancinating pain of the 
"sciatica" that may develop at once follow- 
ing the trauma or may appear at a later 
date. All of the patients in this series de- 
veloped sciatic pain. The average duration 
of these distressing symptoms was forty-two 
months, with the shortest time interval be- 
tween onset and operative intervention be- 
ing three weeks, and the longest twenty-two 
years. The majority of these patients could 
accentuate the sciatic pain by coughing, 
sneezing, and by flexion movements of the 
lumbar spine. A smaller number noticed 
paraesthesias over the areas of pain dis- 
tribution, and motor weakness, often accom- 
panied by actual muscle wasting. Fortunate- 
ly, the attacks of pain are intermittent, and 
a history of an acute episode, with effective 
but slow conservative therapy, to be shortly 
followed by mild trauma and a second acute 
episode is usually obtained. It is apparent 
then that the symptoms of pressure upon one 
or more roots of the cauda equina by a rup- 
tured intervertebral disc do not materially 
difi'er from what our orthopedic colleagues 
have termed lumbo-sacral or sacro-iliac 
strain with sciatica. 

A clinical diagnosis of a ruptured inter- 
vertebral disc may best be obtained by care- 
ful partition of clinical evidence into that 
derived from orthopedic examination, that 
derived from neurologic examination, that 
derived from examination of the spinal fluid, 
and finally that derived from roentgenogra- 
phy. In this series, circumstances have al- 
lowed these studies to be carried out by in- 
dividuals qualified in each particular field. 

Only a cursory orthopedic examination of 
a patient with this lesion is necessary to 
elicit the fact that the individual is seeking 
by postural readjustment to immobilize the 
lumbar region and to relieve pressui-e upon 
the involved sensory root. Paravertebral 
muscle spasm, straightening of the normal 
lumbar lordosis, elevation of the pelvis on 
the affected side, with scoliosis and restric- 
tion of lumbar flexion, were noted in a ma- 
jority of the patients in this series. Local- 
ized tenderness in the transverse process 
adjacent to the ruptured disc was not an 
unusual finding. All of the patients dem- 
onstrated sciatic pain or low back pain with 
the straight leg raising test — a procedure 
which fundamentally falls into the realm of 
neurology, although commonly accepted as 
an orthopedic diagnostic maneuver. 



Febiuary, 1040 



LOW BACK PAIN— WOODHALL ET AL. 



97 



Lasegue's sign, as we have noted, was in- 
variably present in our patients, but actual 
tenderness over the sciatic nerve was an in- 
frequent finding. Eighteen of the patients 
in this series exhibited an absent or dimin- 
ished Achilles tendon reflex, and 17 patients 
exhibited a varying degree of segmental 
sensory loss, predominating in the derma- 
tomes immediately below the actual site of 
the lesion. It has been stated by Barr and 
his associates that neurologic chanpres may 
be totally absent in half the cases of rup- 
tured intervertebral discs. We are inclined 
to agree with Love<"'' and FincherC" that a 
meticulous neurological examination will 
demonstrate neurological deficit in the ma- 
jority of cases. Indeed, the repeated find- 
ing of neurological deficit in patients with 
sciatica without ruptured intervertebral disc 
or other types of mechanical pressure upon 
the roots of the cauda equina has opened, in 
our opinion, a fertile field for further study. 
Only two of our patients presented normal 
neurological findings, if the Lasegue test is 
excepted. Ten of the patients exhibited 
motor weakness and measurable muscle 
atrophy. 

In two patients, rough fasciculation was 
noted in the calf musculature. It appears 
obvious, however, that patients with a nega- 
tive neurological examination, and even 
those with symptoms only suggestive of a 
ruptured intervertebral disc should be given 
the benefit of spinal fluid studies. 

The estimation of the total protein con- 
tent of the spinal fluid is the only laboratory 
examination of any value in the further 
diagnosis of ruptured intervertebral discs 
situated in the lumbar region. The total 
protein was 40 mg. or more per 100 cc. in 
11 cases in this series, and 80 mg. or more 
per 100 cc. in 12 cases. In two cases re- 
ferred from other institutions after lipiodol 
injection, the total protein content of the 
spinal fluid was not determined. Elevation 
of the total protein of the spinal fluid is 
apparently a measure of root irritation, and 
only in rare instances of complete block by 
the displaced fragment of disc tissue is it a 
measure of circulatory deficiency. It has 
been shown that a false normal reading may 
be obtained if the lumbar puncture is made 
at a distance from the affected root, or if 

11. Fincher, E. F., and Walker, E. B.: Displace- 
ment of the Intervertebral Cartilage as a 
Cause of Back Pain and Sciatica, South. M. J. 
31: 520 (May) 1938. 



too large a quantity of fluid is removed for 
chemical study. Routinely, therefore, such 
diagnostic lumbar punctures are made in the 
interspace between L IV and L V, or at the 
lumbo-sacral articulation; and only the first 
2 to 5 cc. of fluid are retained for total pro- 
tein estimation. That a normal total pro- 
tein content of the spinal fluid may be found 
in the presence of a ruptured intervertebral 
disc is indicated by a review of the reported 
cases, in which 20 per cent showed a total 
protein below 40 mg. per 100 cc. It has 
been our experience in two patients with 
ruptured discs to observe a previously re- 
corded high total protein content fall to a 
normal level after simple rest in bed. The 
cell count of the spinal fluid specimen has 
been uniformly within normal limits. The 
Pandy reaction has been positive, as ex- 
pected, in the cases with a total protein 
reading above 40 to 50 mg. per 100 cc. 
No change in the normal dynamics of the 
spinal fluid has been observed in this series, 
although the reverse Queckenstedt described 
by Love has not been used. 

The clinical diagnosis of a ruptured inter- 
vertebral disc as the cause of low back pain 
and sciatica — and this diagnosis can only be 
a presumptive one — is based upon a history 
of trauma to the lumbar region with recur- 
rent attacks of pain; with orthopedic signs 
of paravertebral muscle spasm, limitation of 
lumbar flexion and a positive straight leg 
raising test; with neurologic dysfunction as 
noted by an absent or diminished Achilles 
tendon reflex and sensory loss over an ap- 
propriate dermatome; and finally with an 
elevated total protein content in the spinal 
fluid. The diagnosis is confirmed and the 
ruptured disc exactly localized by fluoro- 
scopy and roentgenography of the subarach- 
noid space after the injection of iodized oil. 
A study of plain roentgenograms of the 
lumbo-sacral region of the spine is of little 
aid in the diagnosis of this lesion. The most 
characteristic finding is a narrowing of the 
intervertebral space, probably due to loss of 
disc substance. The scoliosis and partial 
obliteration of the normal lordosis may be 
observed in most cases. For fluoroscopic and 
roentgenographic contrast studies, five cc. of 
iodized poppyseed oil (lipiodol) are injected 
into the lumbar subarachnoid space. The in- 
jection may be made in any of the lumbar 
interspaces. A free flow of spinal fluid 
should be obtained to prevent the accident 



98 



NORTH CAKOUN'A MEDICAL JOURXAL 



Febiuaiy, 1940 



of an epidural injection, which is disastrous 
to the contemplated study or to any future 
lipiodal investigation. At least 5 cc. of the 
opaque substance should be used, inasmuch 
as the characteristic defect is quite small. 
We have had no experience with the use 
of air as a contrast media nor have we ex- 
perienced over the past ten years any un- 
toward sequelae with iodized oil. Unfavor- 
able reactions may occur with lipiodol not 
especially prepared for subarachnoid injec- 
tion. Clinical observations by Globus"-' 
failed to demonstrate neurologic sequelae in 
ninety patients. It is our feeling that care- 
ful choice of patients for lipiodol injections 
will greatly reduce unnecessary examina- 
tions and potential danger from untoward 
reactions. 

The equipment for the examination con- 
sists of a tilting fluoroscopic table with a 
suitable switch, so that instantaneous roent- 
genograms may be made of suspicious de- 
fects noted on the fluoroscopic screen. Be- 
fore the study is commenced, the patient 
should be allowed to sit up for at least thirty 
minutes, so that the lipiodol may collect as 
a single mass in the cul-de-.sac. Since the 
lesion to be demonstrated is a small, ante- 
riorly and most often laterally placed mass 
opposite the intervertebral space, the patient 
is placed face down on the tilting table, and 
the lipiodol as a unified mass is directed 
rostrally by suitable manipulation of the 
table. A constant filling defect is at once 
recorded in the anterior-posterior projection, 
and lateral views with each side down in 
turn are recorded by repeated manipulation 
of the contrast media. (Fig. 1.) Occasional 
resumption of the sitting posture for an ad- 
ditional thirty minutes may be necessary if 
the iodized oil shows a tendency to fragment 
into globular masses. Similar fluoroscopic 
study is next carried out with the patient 
resting on his back, in order to explore the 
posterior aspect of the subarachnoid space, 
and to rule out the possibility of a spinal 
cord tumor in this general location. Finally, 
all studies are repeated and suspicious areas 
re-examined twenty-four hours later ; for it 
has been demonstrated that .small defects 
may be more clearly demarcated at that time 
by the lipiodol column as it traverses the 
dural reflexions of the roots. (Fig 2.) 

12. Globus, J. H.: Contributions Made by Roent- 
penographic Evidence After the Injection of 
Iodized Oil, Arch. Neurol, and Psychiat. 37: 
1077 (May) 1937. 



A. 




Fig. 1. (.\.) Lipiodol injection localizing ruptured 
intervertebral disc at Lumbar IV, right — anterior- 
posterior projection. (B.) Lateral projection, with 
defect marked by arrow. 

The differential diagnosis of a rupture of 
the intervertebral disc must consider tumor 
of the Cauda eguina, hypertrophy of the liga- 
mentum flavum, arachnoiditis with radiculi- 
tis of the Cauda equina, and those ill-defined 
and poorly understood cases of "sciatica" 
that fulfill the requirements of the clinical 
picture of a ruptured disc but fail to show 
the characteristic defect in the lipiodol study. 
Two tumors of the cauda equina, three ex- 
amples of hypertrophied ligamenta flava, one 
chronic arachnoiditis, and eight ca.ses of 
obscure sciatica were encountered among the 
patients without typical ruptured discs. Thf 
number of patients in this group has ex- 
panded rapidly, and it furnishes a wide field 
for further clinical research. In our experi- 
ence, the various disturbances that simulate 
a rupture of the intervertebral disc may be 
readily and accurately differentiated only by 
lipiodol injection. 

The ruptured portion of the intervertebral 




LOW BACK PAIN— WOOUHALL ET At, 
B. 



99 



Fig. 2. (Aj l.ipicKlcil injiilioii Icicilizing ruptured 
intervertebral disc at Lumbar IV on left side. 
(B.) Twenty-four hour plate illustrating more 
definite outline of defect and continued failure of 
root filling. 

disc is resected either extradurally or trans- 
durally by a simple laminectomy. (Figs. 3 
and 4.) The removal of the appropriate 
spinous process, the beveling of the adjacent 
spines, and the partial resection of a single 
lamina give sufficient exposure for the re- 
moval of a unilateral protrusion. A centrally 
located or bilateral protrusion will necessi- 
tate a wider resection of the laminal arch. 
All lesions are first approached transdurally 
in order to ascertain the location of the rup- 
tured fragment, to inspect the involved root, 
to remove the previously injected lipiodol, 
and to allow the operator to estimate later 
the relief obtained after resection of the 
ruptured disc. In the majority of cases with 
laterally placed lesions, the involved root 
was edematous and injected and the rounded 
contour of the disc fragment could be visual- 
ized beneath the root as it entered its dural 
reflexion. In all but two cases, the disc was 
approached extradurally. It is not necessary 




Fig. 3. (A.) Intradural appearance of edematous 
nerve root. (B.) Extradural approach to ruptured 
di.sc. (C.) Actual disc fragment after removal. 
The laminectomy is more extensive than that 
routinely performed. 



"'•••■•- '•• r.^'" 


t 


Ifr " ^1 ^v 1 


R^ 




My 


L 


Vl 


^w 


%:-^ 


j3 ^ 


^^ 


ftr-^ •^^J,^^ if^l 


b 


(%^ 


^d 


t 


^^ ^ 


^r 


^^,yf<r" 


Y jL-^""^ 


<^<i^ 


^-4 







Fig. 



4. Actual bon> defet t in simplihed and usual 
approach to rupturi'd disc fragmtnt 



to resect the articulating facets, inasmuch as 
the removal of the ligamentum flavum will 
afford adequate exposure of the protrusion. 



100 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



In most cases, upon incision of the posterior 
longitudinal ligament, the ruptured frag- 
ment or fragments will extrude spontane- 
ously. Occasionally, the disc tissue must be 
curetted out piecemeal. Hemorrhage from 
the anterior dural venous plexus may be 
anno.ving, but it is readily controlled by a 
muscle pack. With careful hemostasis, all 
operative wounds may be closed without 
drainage. In only two cases was fusion of 
the lumbo-sacral articulation added to the 
pi'ocedure described. Although edema and 
degenerative changes have been noted by 
Deutcher and Love"-" in a pathologic study 
of their material, such changes were not 
ob.served in the resected specimens in this 
•series. 

No postoperative complications were en- 
countered among these patients, and there 
were no operative fatalities. Patients were 
kept supine for twelve to fourteen days, and 
were discharged with a lumbo-sacral belt, to 
be worn for three months. They were ad- 
vised to return to light exercise at the end 
of one month, and to their usual work at the 
end of three months. Three of the ruptured 
discs were located at lumbar three, twelve 
at lumbar four, and ten at the lumbo-sacral 
articulation. All patients in this series have 
been completely relieved of their sciatic pain, 
and all but two have been relieved of the 
low back pain as well. No recurrence has 
as yet been observed, although the post- 
operative interval, varying from eighteen 
months to three months, is far too short to 
estimate adequately the permanency of this 
clinical syndrome or to evaluate its present 
treatment. 

Abstract of Discussion 

DR. W. W. VAUGHAN (Durham): The history, 
signs, symptoms, and physical findings have been 
discussed by Dr. Woodhall, and therefore this part 
of the discussion vnU be confined almost entirely to 
the technical af^pect of the use of fluoroscopy and 
x-ray films in the diagnosis of herniated interverte- 
bral discs. 

Oftentimes, one may .siispect such a lesion by 
examination of routine roentgenograms of the region 
involved. The most characteristic finding is nar- 
rowing of the cartilage between two vertebrae, and 
rarely, on extremely good films, one is able to see 
the posterior displacement of the longitudinal liga- 
ment of the spine. These findings are only pre- 

13. Deutcher, W. G.. and Love, J. G.: Pathologic 
Aspects of Posterior Protrusions of the Inter- 
vertebral Discs, Arch. Path. 27: 201 (Feb.) 
1939. 



sumptive and should be confiniied by the use of 
lipiodol or some contrast media. 

Lipiodol should be given in the lumbar region, 
since the majority of these lesions occur in this 
anatomical location. The interspace between the 
first and second lumbar vertebrae is usually the 
elective site of the injection, and after removal of 
a sufficient amount of spinal fluid for laboratory 
studies — usually about 15 cc. — 5 cc. of either 20 
per cent or 40 per cent lipiodol is injected into the 
spinal canal. The patient is allowed to remain in 
the supine position for about one hour, but it is 
essential that at least one hour previous to the 
x-ray examination, the patient be kept in an up- 
right position, either sitting or walking around. 

The first part of the x-ray examination is done 
with the patient in an almost erect position, and a 
detailed study is made of the lower portion of the 
spinal canal. It is essential that the fluoroscopist 
have his eyes well accommodated, and it requires 
at least ten or fifteen minutes in a dark room to 
acquire maximum visual acuity. The patient's head 
is gradually lowered, and the lipiodol flo s slowly 
up the canal. Any questionable defects that are 
noted in the column of the contrast media should 
be recorded by roentgenograms. Sometimes it is 
necessary to elevate the feet to a 45 to 60 degree 
angle in order to promote further flowing of the 
lipiodol up the spinal canal. Due to the specific 
gravit.v of the opaque media, it will flow along the 
anterior portion of the canal, and any defect pro- 
duced by a proti-usion of one of the intervertebral 
discs will be noted. .After the lipiodol has been 
allowed to flow up the canal as far as symptoms 
justify, the patient is again placed in the upright 
position and allowed to remain in the sitting posi- 
tion for about one hour. The previously described 
examination is repeated with the patient lying on 
his back. This is done to eliminate the possibility 
of a spinal cord tumor. 

The following day. the entire examination should 
be repeated. This is due to the fact that there is 
quite a variation in the extent of protrusion of 
these discs from hour to hour, apparently due either 
to activity of the patient or to position at the time 
of examination. This indicates that the injured 
discs are quite mobile. 

There is one thing I would like to mention in 
connection with sciatica. Every once in a while we 
find a patient who says ht has sciatica, who may 
have diabetes. 

I examined a patient at our hospital, and at first 
found only a small filling defect. At the second 
x-ray examination one of the largest herniated in- 
tervertebral discs I have ever seen was demonstrated. 
These things are extremely mobile and they are not 
always easy to demonstrate from the x-ray stand- 
point. 

In brief, it may be .said that they arc usually 
unilateral, but frequently they lie in the mid line 
and produce filling defects. These are sharply 
demarcated and always lie opposite the cartilage 
interposed between the bodies of the vertebrae. 

Differential diagnosis must be made between her- 
niated intervertebral discs and tumors, especially 
with multiple meningiomas or neurofibromas. These 
tumors usually lie along the posterior aspect of the 
s-pinal cord, and physical examination will often- 
times aid in the differential diagnosis. 

A single lesion, such as might occur from meta- 
static malignancy, is rarely encountered. Such a 
lesion, however, may be diagnosed by the plain 
films without lipiodol studies because of the de- 
sti-uction of bone in the vicinity, especially the 
laminal arches. 

DR. D. E. ROBINSON (Burlington): I would 
like to ask two questions: Does Dr. Woodhall foil 



February, 1940 



GYNECOLOGY AND UROLOGY— BENBOW 



101 



justified in using lipiodol, even though he has a 
total protein, say, of 10 or 15 milligrams in a 
suspected case ? 

The second question: Does' he find small nodules 
in any condition other than these cases ? 

DR. BARNES WOODHALL (Durham): In answer 
! to Dr. Robinson's question, 1 may say that we rarely 
j inject lipiodol in the presence of a normal protein 
content. However, if the neurological findings are 
quite striking, in perhaps 10 per cent of the cases, 
lipiodol is injected even though the total protein is 
low or normal. 

As far as nodules are concerned, they are tiny 
opaque disturbances in the body of the vertebra. 
We see them very often in noiTnal individuals who 
have no complaints at all. 



THE RELATIONSHIP OF GYNECOLOGY 
AND UROLOGY 

Edgar V. Benbow, M.D. 
Winston-Salem 

Often we examine patients who complain 
of frequency of urination, and find no 
pathology in the urinary tract, but some 
other condition such as a fibroid of the lower 
anterior wall of the uterus or of the cervix 
jutting- into the posterior wall of the blad- 
der; a retroverted uterus with its cervix 
pointing against the bladder, thus irritating 
the trigone ; a pathological anteflexion of the 
uterus with the fundus jutting into the blad- 
der; a carcinoma of the cervix elevating and 
indenting the bladder; or a mass in the 
pouch of Douglas which presses the uterus 
forward into the bladder, thus elevating the 
trigone. This elevation of the trigone is im- 
portant from a pathological standpoint. Just 
as important is the depression of the trigone. 
After nearly every delivery there is some 
depression of the anterior vaginal wall, 
which increases with the number of de- 
liveries and with age and which gives rise 
to a cystocele. Trabeculae are formed in the 
bladder as a result of hypertrophy, and hold 
residual urine. Bacteria grow readily in this 
residual urine, giving rise to cystitis, first in 
the trigone and later in the remaining por- 
tion of the bladder. Pus and fibrin may 
form here. The fibrin may act as a foreign 
body and become a center for stone forma- 
tion. This condition cannot be cured by 
medication if the cause of the pathology is 
left. The cystocele must be repaired if we 
expect a cure. 

We have examined patients with symptoms 
\ of renal colic, and found no stone, but ureth- 



Re.ad before the Second General Session of tlie Medieal 
Society of the State of North Carolina, Bermuda Cruise, May 
13, 1939. 



ritis. This happens too often to be a mere 
coincidence. 

In the normal bladder the sphincter muscle 
separates the bladder proper from the 
urethi-a, and may be seen as a definite promi- 
nence. It is not a continuous muscular ring 
like the sphincter ani, but. at the junction 
of the trigone and urethra its fibers pass into 
the muscles of the trigone on either side ; so 
that when the sphincter contracts it elevates 
the trigone and presses it again.st the 
urethra. In cystocele a fallen trigone is pull- 
ing down on the sphincter of the bladder; 
the sphincter loses its tone and the patient 
becomes incontinent. Later the bladder may 
get so low that the patient is not incontinent, 
but must elevate the bladder with her fingers 
in order to empty it. This prolapse of the 
bladder also causes a pulling and stretching 
on the ureters, with consequent narrowing 
of their lumen ; this in turn causes a certain 
amount of obstruction to the flow of urine in 
the ureters, leading to hydro-ureter, hydro- 
nephrosis, and pyonephrosis. 

Any acute pelvic inflammatory condition 
may cause frequency of urination, because 
the bladder empties itself often in order not 
to become distended and cause pain by press- 
ing on the inflamed part. 

In the normal bladder the air bubble is in 
the midline. If it is to one side the bladder 
is asymmetrical, because the air bubble is 
always in the highest point. This asymme- 
try of the bladder may be seen in parametri- 
tis, pregnancy, myoma, ovarian cyst, and 
other conditions in which the bladder is 
pressed upon by a growth or inflammatory 
process. This may be one means of differ- 
entiating between a large ovarian cyst and 
abdominal ascites. 

Certain changes in the urinary tract may 
occur in case of cancer of the anterior vagi- 
nal wall. At first the cancer may elevate or 
indent the bladder. At this stage the mucous 
membrane of the bladder is normal. The 
lymph ves.sels of the bladder are first blocked 
and the cancer then begins to grow into the 
muscle, causing indentation and edema of 
the bladder wall. The whole mucous mem- 
brane of the bladder is pale and edematous. 
Edema in the bladder indicates that the 
cancer has already involved the muscle of 
the bladder. As the cancer grows deeper into 
the muscle of the bladder and continues to 
compress the lymph vessels, the layers of 
the bladder wall are replaced by cancer cells 



102 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



and there is edema only of the mucous mem- 
brane, with edematous points like a bunch 
of grapes or a number of cysts. This is 
called bullous edema. Between the spots of 
bullous edema is a generalized edema. Over 
the areas of bullous edema only the thin 
mucosa is free of cancer cells. The cancer 
continues to grow until with the cystoscope 
yellowish nodules can be seen, still protected 
by a normal tissue lining, the epithelium of 
the bladder. A few weeks later these cancer 
nodules perforate into the lumen of the blad- 
der, the superficial layer becomes necrotic, 
and the patienfs urine is cloudy and .some- 
times bloody. From the time the urine 
touches the cancer cells, the necrotic cells 
slough off from the bladder toward the 
vagina and the cells from the vagina slough 
off toward the bladder, establishing a vesico- 
vaginal fistula. 

The bladder manifestations of a crrviad 
cancer are usually not in the midline, but to 
one side of the midline. The first elevation 
of the bladder is usually near one of the 
ureteral orifices. The cancer may grow into 
the muscle of the ureter and cause obstruc- 
tion, with consequent uremia. The pain on 
one side which the patient complains of may 
be due to a hydronephrotic kidney or hydro- 
ureter. About 75 per cent of patients with 
cervical cancer die of uremia. 

Cancer of the body of the uterus never 
causes edema of the bladder, because it 
usually grows into the peritoneal cavity. 

Cancer of the tubes is too rare to discuss. 
Cancer of the ovaries may cause changes in 
the lateral bladder wall. We may see some 
indentation of the bladder wall, but not the 
edema or the perforation, because the easiest 
way for it to grow is into the abdomen. An 
enlarged cancerous gland in the parame- 
trium, growing against the ureter and com- 
pressing it, may cause hydro-ureter and 
hydronephrosis. An ovarian tumor, by pres- 
sure upon the ureter, may have the same 
effect. 

Adenomyosis, or endometriosis, is a con- 
dition in which endometrial tissue of the 
uterus is found in some other location of the 
body. It bleeds regularly at the menstrual 
periods. If it is located in the ovaries it 
leads to the formation of chocolate cysts. If 
it is located in the bladder wall, the patient 
will pass bloody urine at the menstrual pe- 
riod, and will have pain in the bladder, 
which disappears after menstruation. The 



pain is due to the swelling of the endometrial 
tissues in the bladder wall. This endometrial 
tissue may be observed through the cysto- 
scope, and if .some of this tissue is removed 
it has the same microscopic appearance as 
the endometrial tissues lining the uterus. 
Adenomyosis may originate from blood 
passed out through the fallopian tubes ; from 
cells transplanted at the time of an opera- 
tion where the uterus is cut into, as in caesa- 
rean section ; or from misplaced fetal cells. 
Adenom.vosis ma.v be treated by resection of 
this area of the bladder, by x-ray or radium 
to the ovary — thus castrating the patient — 
or by radium needles into the bladder tumor 
itself. After the menopause the patient has 
no more trouble from endometriosis. 

Ectopic pregnancy usually causes no signs 
in the bladder unless a large haematocele 
forms, causing elevation or indentation of 
the bladder. 

Pain in the kidney region may be a re- 
ferred pain from adnexal disease, and the 
adne,xal disease may be overlooked unless a 
pelvic examination is made. Cases have been 
reported of pyosalpinx and abscess of the 
parametrium perforating into the bladder. 
The former will not heal without an opera- 
tion and closure of the sinus tract ; the latter 
may heal spontaneously. This is because the 
abscess of the tube arises in a pre-formed 
cavity, while that of the parametrium is not 
in a pre-formed cavity and will heal by 
granulation. 

Tuberculosis of the kidney is often asso- 
ciated with tuberculosis of the adnexa, and 
the reverse is also true. If we find tubercu- 
losis at one of these places we should look 
for it at the other. 

There are cases on record where dermoid 
cysts have perforated into the bladder, 
emptying their contents of hair, cartilage, 
teeth, and sebaceous material there. 

Certain changes take place in the bladder 
at the menopause. There is atrophy and loss 
of tone in the sphincter, and if the patient 
has had many deliveries and has a cystocele 
dragging down on the sphincter she is apt 
to lose a few drops of urine when the abdo- 
minal pressure is increased. The mucous 
membrane of the trigone and that surround- 
ing the trigone becomes atrophic and more 
grayish in color. 

In the later months of pregnancy pyelitis 
is more apt to develop than in the early 
months. Pyelitis is apt to develop in preg- 



Fohmary, 1940 



GYNECOLOGY AND UROLOGY— BENBOW 



103 



nancy because of the indentation of the 
bladder by the enlarged uterus, which im- 
pedes the flow of urine through the ureter. 
Also in the later months of pregnancy, the 
ureters take a more direct course through 
the bladder wall, causing their mouths to 
gap open. This favors a reflux of urine from 
the bladder back into the ureter. Probably 
the constipation of pregnancy also has some- 
thing to do with the development of pyelitis, 
since colon bacilli may enter the urinary 
tract through the lymphatics from the in- 
testinal tract. A retroverted and enlarged 
uterus may cause pyelitis in a similar man- 
ner, and the cervix pointing against the 
bladder may irritate the trigone. 

Incovtinencc of urine may be due to fis- 
tulae. There may be ureteral fistulae, blad- 
der fistulae, or urethral fistulae, opening into 
the vagina. A bladder fistula may be caused 
by the knife of the operator; by a diflieult 
delivery, causing necrosis of the tissue ; b.v 
cervical or vaginal cancer; or by pressure 
from a pessary. The fistulae between ureter 
and vagina are usually caused by cutting the 
ureter during an operation. This type of 
fistula may be complete or incomplete. In 
the complete type the entire output of urine 
from the kidney on the affected side empties 
into the vagina. In the incomplete type a 
part of the urine from the affected side 
empties into the bladder and part of it into 
the vagina. Incontinence may be absolute or 
incomplete. Incontinence may be due to con- 
genital malformations, such as hypospadias 
and epispadias ; to diseases of the central 
nervous system — e.g., tabes ; to wounds of the 
spinal cord; and to injury to the sphincter 
muscle itself (during an operation or a de- 
livery, or by extraction of foreign bodies 
from the bladder). Other acquired causes of 
incontinence are senility with atrophy of the 
sphincter, weakening diseases with a.sthenia 
of the tissues, a cystocele, or a prolapsed 
uterus. Incontinence may also be caused by 
an incarcetrated tumor of the pelvis which 
presses the trigone and sphincter against the 
urethra, giving the overflow of retention. I 
had such a case caused by pregnancy taking 
place in a retroverted uterus. As the uterus 
enlarged in the hollow of the sacrum it 
pushed the cervix against the urethra, thus 
obstructing it. While speaking of incontin- 
ence, I would like to tell of a little girl who 
had been wet since infancy. She had been 
to doctors numerous times, and without 



thorough examination had been "treated" 
for bed-wetting, with no results. As she 
grew up she was beaten on numerous occa- 
sions, but the condition continued. Finally 
she was taken to a doctor who gave her a 
thorough and careful examination. It was 
found that she had three kidneys and three 
ureters. Two of the uretei-s led normally 
into the bladder: while the third emptied 
into the vagina. These cases are subject to 
ascending infection. If the kidney is good 
the ureter should be transplanted into the 
bladder, but if the function of the kidney is 
gone it should be extirpated. In these ca.ses 
the ureter always empties into the side of 
the vagina on which the kidney is located. 

Kraurosis of the vulva may be caused by 
the irritation of sugar in the urine. About 
25 per cent of cases of kraurosis are found 
in diabetics. Normal urine in incontinence 
may also cause kraurosis. 

Pain in the adnexal region may be a 
referred pain from the bladder. I have in 
mind a case illustrating this. Pelvic exami- 
nation revealed no definite trouble in the 
adnexal region. The patient was referred to 
a urologi.st who, with a cystoscope, found 
minute ulcerations of the bladder mucosa, 
which were probably due to a deficiency of 
vitamin B. This patient was given vitamin 
B and her symptoms rapidly cleared up. 

A paper on this subject would not be com- 
plete without mentioning the importance of 
an infected cervix as a focus of infection in 
disea.se of the urinary tract. Winsbury- 
WhiteC* of London states that many ca.ses 
of loin pain are alleviated when an infected 
cervix is dilated and cauterized. It is inter- 
esting to recall that pyelitis occurs much 
more frequently in females than in males, 
and that hydi-onephrosis is twice as common 
in women as in men. Winsbury-White also 
states that in 87 per cent of ca.ses of stone 
of the upper urinary tract there is residual 
infection of the lower urinary tract or of 
the genitals. Infection of the genitals may 
give rise to a lower urinary tract infection, 
and this in turn cau.se an upper urinary 
tract infection with stone formation. Upper 
urinary tract infection does not have to come 
through the lumen of the ureter, but may 
ascend by way of lymphatics, which may 
arise from the genitals as well as from the 
lower urinary tract. Winsbury-White in- 
jected India Ink and dead tubercle bacilli 



1. Winsburi'-White, in the Journal of Urology, Nov., 19 



104 



XOr.TH CAROLIXA MEDICAL JOURNAL 



February, 1940 



into the cervices of white mice, and then by 
studying the cross sections with the micro- 
scope traced the course of the dye from the 
cervix to the upper urinary tract through 
the lymphatics. He further states that a 
mildly dilated upper ui'eter and pelvis may 
result from foci in the cervix. Adhesions 
may form between the adjacent ureter and 
pelvis, and stenosis of the ureter may result 
from contractions, leading to hydronephrosis 
and even to stone formation. 
Summary 
Many patients present themselves with 
urological symptoms when their condition 
is a gynecological one, and vice versa. 
Furthermore, a urological condition may 
have its primary etiology in the genital tract. 
The reverse of this is also true. We should 
have this close relationship in mind in mak- 
ing a urological or a gynelogieal examina- 
tion. 

Abstract of Discussion 

DR. HAMILTON \V. McKAY (Charlotte): I think 
this paper is timely in emphasizing the interrela- 
tionship between symptoms produced by the urinary 
tract and those of the interior genitalia. 

In a female patient with urinary symptoms, fre- 
quency is probably the most common sj-mptom. I 
think the most valuable procedure that can be at- 
tempted is for the doctor himself to make a thorough 
inspection of the female organs. For years I have 
insisted that in examining a female patient, adult 
or child, with urinary sjTiiptoras, the doctor should 
obtain a catheterized specimen of urine himself. 

The female urethra reflects- oftentimes what is 
taking place in the bladder and kidneys. Time and 
time again we see patients referred with a diagnosis 
of pyelitis, nephritis, and various other infectious 
processes of the upper urinary tract, who have been 
repeatedly examined by the cystoscope, when an 
inspection of the urethra alone reveals an infection 
in the deep glands of the urethra, in Skene's gland 
and others. 

DR. DAMD J. ROSE (Goldsboro): I want to 
call attention to one finding upon which little stress 
has been put, and that is a stone in the lower 
ureter below the iliopectineal line. I merely call 
attention to that on account of a method used in 
the treatment of this condition in the ureter below 
the brim of the pelvis. These stones have been 
easily removed under light anesthesia, by a very 
simple technique outlined by Dr. Cobb's paper on 
vaginal ureteral lithotomy. 

DR. BENBOW": I want to say one more word: 
I think that the importance of the cervix of the 
uterus as a focus of infection has been overlooked. 
Throat men all talk on the tonsil, and medical men 
speak of the teeth, the mastoid, the appendix, and 
tile gall bladder as point.'; of infection. Yet they 
do not take the cervix as a focus of infection 
seriously enough. 

Whenever I have to do a hysterectomy I make it 
a rule to take the cervix out, too, if it is bad. If 
the cervix is all right, there is no need to take it 
out; but if it is bad, there is no cause to leave it 
in. Severe cases of arthritis and rheumatism have 
cleared up when an infected cei-vix has been re- 
moved. 



PRESENT DAY DIAGNOSIS AND 

TREATMENT OF CHANrROIDAL 

INFECTION 



Walter L. Thomas, 
Durham 



M.D. 



Fifty years ago, A. Ducrey'" first de- 
scribed small gram negative chain bacilli in 
smears from ulcerative lesions on the exter- 
nal genitalia. For many years the exact role 
played by this bacillus was not completely 
understood. Much of the confusion was due 
to inability to culture the organism and to 
the fact that the causative agents in the so- 
called newer venereal ulcers and buboes, such 
as lymphopathia venereum, granuloma in- 
guinale, etc., had not been discovered. In 
recent years, the perfection of specific skin 
tests and laboratory procedures has made 
the differential diagnosis very accurate. In 
a review of our patients we have been im- 
pressed with the number of patients with 
multiple venereal infections — e. g., syphilis 
and chancroid, lymphopathia venereum and 
syphilis. This is natural because of promis- 
cuous sexual contacts. Every illicit sexual 
exposure is a potential source of infection 
with H. ducreyi, Treponema pallida, Neis- 
seria gonorrheae, inclusion bodies of Dono- 
van or the virus of lymphopathia venereum. 

The recognition of chancroidal infection 
in the male based on clinical grounds is com- 
paratively easy. No clinician, by simple 
ob.servation of an ulcerative or bubonic lesion 
in the female, can accurately ascribe the 
lesion to a particular disease process. In 
other words, a chancroidal lesion may simu- 
late the lesion of syphilis, of granuloma in- 
guinale, of lymphopathia venereum, of a 
furuncle, of a fu.so-spirochaetal ulcer, of 
tuberculosis, of carcinoma or of fungus in- 
fection. We must depend upon our dark 
field e.xamination, smears, cultures, skin 
tests and biopsies to give correct diagnosis. 

A chancroid or soft chancre of the vulva 
usually affects the greater or lesser lips. The 
vaginal fornix, and even the cervix, may be 
affected. Within 12 to 24 hours after in- 
fection, there appears a small reddish macule 
at some abrasion of the skin or mucosa. This 

From Ihe Depjirtment (tf Obstetri«-s and (iynecolofry. Duk*' 
University' Hospital. Read l»efore the Section on GynecolOf!> 
and Ot)stetries. Medical Society of the State of North Carolina. 
Bermuda Meeting. May lu, 1939. 

(1.) Ducrey, A., in Congres Internal, de Dermatol, 
et Syphilogr., Paris, 1889, p. 229. 



Febniaiv. 1ft 10 



CHANCROIDAL INFECTION— THOMAS 



105 



early lesion is often not noticed by the female 
and she may date her coitus a week or more 
before. The early lesion is generally fol- 
lowed by an inflammatory papule, which is 
converted into a pustule in the course of 
from 24 to 48 hours. In a very short time 
the epithelial covering of the involved area 
is lost, the pustule ruptures, and a small 
ulcer is noted. This ulcer has sharp, 
punched-out margins, a rough, grayish base, 
sometimes necrotic, surrounded by a red in- 
flammatory zone, and at times shows indu- 
ration. Involvement of the inguinal lymph 
nodes may be present, and not infrequently 
a chancroidal bubo will suppurate and ul- 
cerate. 

Diugnosix: The failure to diagnose a 
chancroidal ulcer may be of no great con- 
sequence to the ultimate welfare of the in- 
dividual. Most chancroids heal spontaneous- 
ly in due time. On the other hand, to con- 
fuse a chancre or early epithelioma with a 
chancroid would be very serious ; therefore, 
it is more important to examine a suspected 
chancroid patient for simultaneous primary 
syphilis, carcinoma, or lymphopathia vene- 
reum than for the chancroidal infection 
alone. 

The positive diagnosis of a chancroidal 
ulcer or bubo is made by finding the strepto- 
bacillus of Ducrey in a smear or culture from 
the lesion, and by a specific skin test. The 
superiority of the chancroidal intracutane- 
ous test with bacillary antigen over the test 
with antigen prepared from the pus has been 
proven by Cole-Levin<-> and Greenblatt-San- 
derson<^>. The method for the preparation 
of the bacillary antigen from cultures which 
we have used and found very satisfactory 
has been described by Greenblatt and San- 
derson'^' as follows: "To tubes of beef in- 
fusion agar in slants is added 1 cc. of de- 
fibrinated human blood. The blood is inocu- 
lated with 0.1 cc. from an actively growing 
culture and placed under partial oxygen 
tension. To obtain this environment, the 
cotton plug is cut off short and pu.shed slight- 
ly into the tube; the upper portion of the 
tube is heated, but not too much, in a Bun- 
sen flame, and the tube is sealed by insert- 

(2.) Cole, H. N. and Levin, E. A., in J.A.M.A., 

105: 2040, 1935. 
(3.) Greenblatt, R. B. and Sanderson, E. S., in 

Arch. Demiat. and Syph., 36: 486, 1937. 
(4.) Greenblatt, R. B. and Sanderson, E. S., in 

Am. J. Clin. Path., 7: 193, 1937. 



ing a tightly fitting rubber stopper. The 
culture is incubated for from two to three 
days at 37° C. During this period good 
growth takes place in the fluid blood, and a 
lesser growth appears on the surface of the 
slant. After the incubation, the blood as 
well as the surface growth, if any, is re- 
moved with a sterile pipet and added to ap- 
proximately 25 cc. of sterile distilled water 
in a sterile centrifuge tube of sufficient vol- 
ume, and the contents are sedimented by 
high speed centrifugation. The supernatant 
fluid is removed aseptically and discarded, 
and the process is repeated. Two such treat- 
ments suffice to remove most of the hemo- 
globin. The sediment of bacilli and red cell 
debris is suspended in sterile physiologic 
solution of sodium chloride, 10 cc. per slant 
being placed in sterile vials, and heated for 
thirty minutes at 60° C. A 1:10,000 solu- 
tion of merthiolate is used as a pre.serva- 
tive." 

The test is performed by injecting 0.1 cc. 
of the vaccine intracutaneously. The reac- 
tion is read in twenty-four and in forty- 
eight hours. In a negative test, either no 
reaction is seen (after two days) or at most 
a slight erythema, or minimal papule, which 
disappears quickly. In positive te.sts, red in- 
flammatory papules or indurations approxi- 
matelj' 1 to 2 cms. in diameter are seen, 
sometimes with erythematous areas or cen- 
tral pustules. In the interpretation of the 
results of this test, a number of points 
should be considered. Negative results rule 
out chancroidal disease unless the ulcer is in 
a very early stage, less than eight to ten 
days old. A positive result, according to 
Greenblatt and Sanderson*-" "commits one 
to the diagnosis of chanci'oidal infection only 
when the Frei test, the Wassermann test, 
and the histopathological examination for 
malignant disease and for granuloma ingui- 
nale give negative results" — i. e., a positive 
chancroid test is only presumptive evidence. 
When the reactions are interpreted, one 
must keep in mind that the skin tests for 
chancroid and lymphopathia venereum re- 
main positive for life. 

Treatment: The most effective prophy- 
laxis against chancroid or any venereal in- 
fection is abstinence from promiscuous sexu- 
al contact. The technique of chemical 
prophylaxis for chancroidal infection is 
simple and effective if it is applied within 



lOG 



NORTH CAROLINA MEDICAL JOURNAL 



February. 1940 



one hour after exposure. It is still of some 
value as late as eight hours after exposure. 
The female's genitals and adjacent parts 
should be thoroughly washed with soap and 
water; a douche of one-half gallon of soapy 
water, temperature 100 F. should cleanse 
the vagina and cervix. Soap and water will 
destroy the strepto-bacillus of Ducrey. The 
mechanical prophylaxis of the condom is the 
main hope of prevention of chancroid and 
other venereal infections. 

Chancroidal ulcers have been treated local- 
ly with a great variety of drugs. Among 
the numerous preparations used are forma- 
lin, argyrol crystals, nitric acid, copper sul- 
phate, calomel and others. Cleanliness plays 
a main role. 

The culture vaccine of Ducrey bacilli has 
been used therapeutically to a very large ex- 
tent. The French employed a vaccine known 
as "Dmelcos",'^' which was very popular. 
The great disadvantage of this method is 
that it produces very strong general reac- 
tions, a high fever, vomiting, chills and great 
exhaustion. In fact, many thought that the 
beneficial results of the vaccine were due to 
the fever and reaction. 

Sulfanilamide therapy with spectacular re- 
sults is replacing the many prolonged and 
none -too -satisfactory types of treatment. 
Kornblith, etc.,"'' reported a series of 45 
patients treated with oral sulfanilamide. 
There was, without exception, complete heal- 
ing at the end of two weeks, with no ill 
effects due to the treatment. Batchelor and 
Lees'"' treated 10 cases of chancroid with 
sulfanilamide by mouth. Four patients 
represented relapses after treatment with 
"Dmelcos" vaccine. The average number of 
days for cure was nine. There was one 
patient who developed toxic .symptoms from 
the drug. Everj' chancroidal patient that 
we have seen during the past year has been 
placed on this therapy. We are convinced 
that this drug by mouth will cause complete 
healing with eradication of the disease with- 
in one to two weeks. The economic value 
of this treatment is of great importance. 
The treatment is easily carried out and is 
ambulatory. We have no definite plan of 

(5.) Nicolle, C. and DuramI, P., in Presse mod., 

p. 1033, 1924. 
(6.) Kornblith, Boni.-i, A.; Jacoby, Adolph; and 

Wishengrad, Michael, in J. A.M. A., Ill: 523, 

19.38. 
(7.) Batchelor, R. 0. L., and Lees, R., in Brit. 

Med. Jour., 1: 1100, 1938. 



dosage. As a rule we have employed about 
80 grains in four divided doses daily for the 
first three to four days, and then 40 grains 
daily for the next nine to ten days. No 
patient has yet failed to heal promptly under 
this therapy. Local treatment of the ulcer 
or bubo has not been necessary. We feel 
that the sulfanilamide should be continued 
until the process is completely healed. The 
carefully controlled supervision of sulfanila- 
mide by a physician is absolutely necessary. 
The side reactions which may indicate tox- 
icity to the drug should be closely followed. 
One death from sulfanilamide chemotherapy 
would be tragic as chancroidal infection per 
se carries no mortality. Weakness, dizzi- 
ness, loss of sleep, "drunk feeling" and slight 
dyspnea are so common as to be called con- 
comitant reactions rather than complica- 
tions. Fever-rash syndrome, severe cyanosis, 
low hemoglobin content, leukopenia, severe' 
vomiting and gastro-intestinal disturbances 
should indicate immediate discontinuance ot 
the drug. The mode of action of sulfanila- 
mide on the strepto-bacillus of Ducrey has 
not been determined. 

Summary 

1. A very accurate diagnosis of chancroidal 
infection can be made today by culture 
and smear of the strepto-bacillus of Duc- 
rey and by the intracutaneous te.st with 
the bacillary antigen. 

2. More serious venereal infections such as 
lymphopathia venereum, granuloma in- 
guinale and .syphilis must be ruled out in 
every suspected chancroid patient. Early 
epithelioma is also to be differentiated. 

3. Oral sulfanilamide causes complete rapid 
healing within seven to fourteen days. 

4. The carefully controlled supervision of, 

sulfanilamide administration by a phy 
sician is urged. The full cooperation of 
the patient is essential. 

Abstract of Discussion 

DR. T. L. LEE (Kinston): Dr. Thomas- has left 
very little to be said on the subject of chancroida 
infections in and around the vulva. There is om 
thing I would like to emphasize — that is, the dif 
ficulty in differential diagnosis. We are not all si 
fortunate as he in having the laboratory facilitie 
to make an accurate diagnosis. The vaccines havi 
to be fresh. 

At one time, years ago, there was a questioi 
whether a lesion was syphilis. We were satisfie 
to find a spirochete or note its absence. Today w 
go beyond that. We have to make a much nioi 
correct and accurate diagnosis exactly along th 
lines Dr. Thomas demonstrated. 



February, 1U40 



PECTIN IN DIARRHEA— KUTSCHER 



107 



The ROLE OF PECTIN IN DIARRHEA 
G. W. KuTSCHER, Jr., M.D. 

ASHEVILLE 

Before liver was found to be a valuable 
adjunct in the treatment of pernicious 
anemia, it was simply another form of meat. 
Recall what scientific study and publicity 
have done for liver. Something similar may 
result from the research that is now being 
applied to pectin. A few years ago pectin 
was popularly known only as a substance 
used by our wives to make jelly congeal. 
Today it has been so glorified that it is being 
used as a germicide, as an antihemorrhagic, 
as a stimulant to wound healing, in phar- 
macy, and even by bakers to retain moisture 
in bread and cake. It is used to make cheese 
smoother and to temper steel : the ice cream 
maker even finds it valuable in his industry. 
However, as pediatricians we are chiefly con- 
cerned with its use in the treatment of diar- 
rhea. 

A little over a hundred years ago a French 
physician sugge.sted pectin as an antidote 
for heavy metal poisoning, since pectin 
formed an insoluble compound in the pres- 
ence of these metals. The modern concep- 
tion of pectin began when Ehrlich started 
to work with it in 1915. About the .same 
time Hei.ser discovered the value of the raw 
apple diet in diarrhea. He attributed the 
good results to the acid content of the fruit. 
Moro followed a few years later, but he 
attributed the effects obtained to the tannin 
i;ontent of the apples. Malyoth in 1934 was 
the first to ascribe the results of apple diet 
to the pectin content. Much of a theoreti- 
cal nature has been written on the subject 
by many writers since then, but very little 
proof has been offered to support their con- 
jectures. The issue has recently been cleared, 
however, by Manville and his co-workers, 
who have demonstrated that pectin is the 
active constituent of the apple diet and that 
the uronic acids, namely galacturonic and 

J glucuronic, are the essential therapeutic 
Tactions of pectin. 

For more than fifty years it has been 
■ecognized that glucuronic acid possessed a 
letoxifying action in the human intestinal 

ii ;ract. Ehrlich in his original work dis- 

*^ :overed that the chief organic acid in pectin 

« 

jl Ke.id before the Section on IVtIiiitrics, Meciit-al StK-iety of the 
^State of North Carolina, Bermuda Meeting, May 10, 1939. 



is galacturonic acid. Today we realize that 
galacturonic and glucuronic acid have many 
similar properties. Both uronic acids form 
conjugation products with toxins and assist 
in the elimination of the poisons from the 
body. Possibly other fractions may have a 
value in the treatment of diarrhea, but at 
present the two uronic acids .seem to be 
chiefly responsible for the remedial action 
of pectin. 

The irritants in the intestinal tract are 
responsible for the increased peristalsis — 
thus the frequency of the stools in diarrhea. 
Pectin removes these irritants and restores 
normal peristalsis quickly. Pectin not only 
removes the irritants, but also combines with 
both the bacteria and the toxin, making them 
inert. 

Corcoran has demonstrated that pectin 
has a germicidal action at a pH of 5.0 to 
5.5, and that this germicidal action is greatly 
reduced when the pH reaches 6.0 or 6.5. 
Manville agrees that pectin can create a pH 
in the intestines in which ordinary patho- 
genic organisms cannot survive. This germi- 
cidal action of pectin has not been greatly 
emphasized in the literature. 

Practically every writer on the subject has 
remarked on the fact that pectin seems to 
have the property of quickly converting a 
liquid stool into a formed stool. Its value 
in retaining body fluids has been carefully 
demonstrated by several workers. Dehydra- 
tion is thus frequently avoided. Pectin con- 
tains a substance which assists the mucous 
membranes of the intestinal tract to secrete 
mucus. The mucous coating prevents me- 
chanical injury to these mebranes. 

While there are many additional advan- 
tages attributed to pectin, only the above are 
mentioned, because they alone have been 
proven. Summarizing what has been offered : 
Pectin is a beneficial agent in the treatment 
of diarrhea because of its combining action 
with both the causative organism and its 
toxin. It reduces peristalsis by removing 
the irritants present in the intestinal canal. 
Pectin has been demonstrated to have a 
bactericidal action. Bulky stools quickly fol- 
low its use, thus preventing great fluid and 
mineral loss. 

My own experience with the pectin treat- 
ment of diarrhea began two summers ago. 
In 1937 I was so favorably impressed with 
its value in severe diarrheas that I used it 



108 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



in a series of 50 consecutive cases of diar- 
rhea during the summer of 1938. A more 
complete analysis of that study will be re- 
viewed elsewhere. However, I offer for your 
consideration and discussion a few of the 
pertinent observations obtained from that 
study. 

The pectin used was iu the form of a 
powder because I feel that it has definite 
advantages in this form over raw apple* 
The average age of these 50 children was 
23.6 months, the youngest being one month 
old and the oldest 12 years old. A daily 
stool culture was made in each case by a 
competent bacteriologist. In this way both 
a clinical and a bacteriological diagnosis was 
made in each case. Time will not permit a 
detailed analysis of this study; so a rather 
brief summary will be pre.sented to give you 
some idea of the results obtained. 

Bacteriologically, such organisms as these 
were recovered from the stools and were be- 
lieved to be the causative agency in the 
diarrhea : Bargen diplococcus, Escherichia 
Coli Communis and Communior, Salmonella 
Enteritides and Schottmulleri, Shigella Pa- 
radysenteriae (including Hiss, Shiga, Y, and 
Flexner bacillus), Aertryche and Sonne 
dysentery bacillus. It was one of the pur- 
poses of this study to endeavor to find a 
pathogenic organism causing diarrhea which 
could not be subdued by the use of pectin. 
No such organism was discovered. A final 
check on all stools was made to determine 
whether or not the previously found patho- 
genic organism persisted or recurred. These 
check-up studies revealed a complete clear- 
ance of the organism from the stools. 

Clinically, from the history taken when 
the patient was first seen, there was an 
average of nine stools per day on the day 
preceding the time I first saw the child. 
One child was having forty bloody stools 
per day. The first twenty-four hours fol- 
lowing the institution of the pectin treat- 
ment the number decreased to an average of 
four stools per day. Gross blood was pres- 
ent in the stool in seventeen instances but 
it disappeared (on the average) in forty- 
eight hours. Excoriated buttocks healed 



within thirty-six hours. The temperature 
dropped to normal in mo.st instances within 
thirty-six to forty -eight hours, the only ex- 
ceptions being the dysentery cases. The 
rapid disappearance of the toxicity was re- 
markable. Dehydration required no treat- 
ment except in these cases seen late in the 
disease. One child ill for twenty-four days 
before pectin was started was clinically well 
of her diarrhea in forty-eight hours. Pectin 
treatment seems to work about as well in 
the late cases as in those cases seen at the 
onset of the diarrhea. Naturally, late, in 
this instance, does not mean moribund. The 
first normal appearing stool was seen (aver- 
age of all cases) within 2.4 days following 
the institution of the pectin treatment. One 
very interesting feature was the sudden 
cessation of the diarrhea within a few hours 
after the treatment was started. The diar- 
rhea seemed to be checked even before the 
preparation had had an opportunity to pass 
through the gastro-intestinal tract. 

In my practice I believe I have tried all 
the recognized forms of treatment for diar- 
rhea and even some that have not been 
recognized. However, I have never seen such 
quick and satisfactoi'y results as I have with 
pectin. Until .something better is presented, 
pectin treatment will be my choice for all 
forms of childhood diarrhea. 



■This prwliirt is mm- on the market, liiaile by Mead Julii 
and Co., known as I*uetin .\gar with Dextri-Maltuyc. 



Mass Killing. — Devoting: our lives, as we are, to 
the .^avinjr. the conservation of human life, it is in- 
escapable that our first reaction to mass' killing i> 
one of frustration, of futility. How puny are our 
efforts compared with the effect of war. Four years 
of the World War nullified, wiped out, the results 
of probably forty years of medical progress. The 
lifetime of a hundred laboratories, a thousand 
scientists, tens, yes, hundreds of thousands of doc- j 
tors and nurses gone for naught. — Parran, Thomas 
Jr.: Cancer and the Public Health. Science 90: 
2341 (Nov. 10) in.'iil. 



The Costs of War. — Not counting other losses, if 
the material costs of the World War and the arma- 
ment costs since then could have been spent to 
satisfy the basic needs of the people for peaceful 
living, the world today would be experiencing a 
standard of living beyond anything ever dreamed 
of. To attain a higher standard of national health 
is an urgent need in this country — whether the fu- 
ture brings us continued peace or war. — Parran, 
Thomas. Jr.: Cancer and the Public Health, Science 
90: 2341 (Nov. 10) 1939. 



February, 1940 



EDITORIALS 



109 



North Carolina Medical Journal 

Owned and Published by 

The Medical Society of the State of North Carolina, 
under the direction of its Editorial Board. 



EDITORIAL BOARD 

Wingate M. Johnson, Winston-Salcni 

Editor. 
T. W. M. Long, Roanoke Rapids 

Business Manager. 
Paul P. McCain, Sanatorium, Chairman. 
W. Reece Berryhill, Chapel Hill. 
Coy C. Carpenter, Wake Forest. 
Frederic M. Hanes, Durham. 
Paul H. Ringer,, Asheville. 
Hubert A. Royster, Raleigh. 

Address manuscripts and communications to the 

NORTH CAROLINA MEDICAL JOURNAL, 

428 Stratford Road, Winston-Salem. 

February, 1940 

"THE SCARCITY OF DOCTORS" 

The Netv York Times for December 30 
records an interview with Dr. Hugh S. Cum- 
mings, former Surgeon General of the 
United States, immediately after his return 
from meetings of the Health Committee of 
the League of Nations in Geneva. "Dr. Cum- 
mings said that the meetings had been held 
to coordinate efforts in checking the spread 
of disease as a result of malnutrition and 
epidemics arising out of the war . . . 'There 
never have been enough doctors in most of 
the European countries,' he said. 'And those 
that were available are now mobilized. So 
there is going to be a great problem created 
by the scarcity of doctors.' " 

In the Reader's Digest for December — 
pages 19 to 25 — is an article, "Health under 
Hitler", by Dr. Martin Gumpert, "formerly 
head of Berlin City Dispensary for Deformi- 
ty Diseases". In this article Dr. Gumpert 
states that in Germany "Scarlet fever cases 
in 1933 were 79,830; in 1937, 117,544. In 
1938 there were 77,340 cases of dipththeria ; 
in 1937, 146,733 ... In Germany rickets 
shows an appalling increase; in Munich only 
3.5 per cent of the .school children are free 
from its symptoms . . . Dysentery . . . has in- 



creased 300 per cent under Hitler . . . The 
German death rate has inci'eased for nearly 
every age group, but particularly for the 
levels of one to 15 years and 20 to 45". 

"What is being done to stop the decay in 
the health of the German people? Is the edu- 
cation of the rising generation of doctors be- 
ing improved? 

"On the contrary. Two laws passed in 
1939 are significant. One cut down the pe- 
riod of medical study by two years. The 
other legalized the activities of quacks and 
nature healers: 'Those who feel within them- 
selves a special call to nature healing can 
dispense with higher education or any form 
of examination.' For every four certified 
doctors in Germany there is one so-called 
nature healer." 

These two views — one, that of a veteran 
American public health worker, the other of 
a German physician — should give pau.se to 
those who would prescribe liberal doses of 
European political medicine as the tonic 
needed to improve the health of the Ameri- 
can people, even though, according to the 
Associated Press on January 6, "Surgeon 
General Thomas Parran . . . today described 
the American people as the healthiest people 
in the world, and the present generation as 
the healthiest in the nation's history." If 
the political medicine practiced in Europe — 
which had its beginning in Russia and Ger- 
many — offers such tremendous advantages 
both to the public and to the physicians, why 
should there be such a scarcity of doctors 
reaping its benefits? And why, after half a 
century of this medical Utopia, reaching its 
climax under the present Nazi regime, 
should the health of the German people ret- 
rograde so rapidly? 

Doubtless many Europeans who, in the 
beginning, favored a .system of political 
medicine would now like to see it abolished ; 
but it is too late. Let the people of America 
take warning from their pathetic example. 
It will be agreed that there are many other 
factors than socialized medicine to explain 
health conditions in Germany and other 
European countries ; but the stubborn fact 
remains that the socialization of medicine 
was the entering wedge for totalitarianism 
in Germany and in Russia. 



no 



NORTH CAROLINA MEDICAL JOURNAL 



February. 19-10 



A MODERN CLASSIC 

DOCTOR AND PATIENT, by the late 
Francis W. Peabody, is a slim volume of only 
'J5 pages, published by The Macmillan Com- 
pany. It is worth far more than the $1.50 
asked for it. 

This little work belongs in Sir Francis 
Bacon's select group of books which deserve 
to be chewed and digested. It contains only 
four essays, but they reveal the soul of a 
great physician and a great humanitarian. 
The titles are : "The Public and the General 
Practitioner", "The Care of the Patient", 
"The Physician and the Laboratory", and 
"The Soul of the Clinic". The author's theme 
is well expi'essed in the subhead on the title 
page: "Papers on the Relationship of the 
Physician to Men and Institutions". 

The first paper is devoted to proving the 
statement: "Never was the sound general 
practitioner more important than he is to- 
day." Here is no fulsome eulogy of the old 
horse and buggy doctor, but a logical analy- 
sis of the need for men trained to see the 
body and the mind as a whole. The value of 
specialists is recognized, but the need for the 
wise clinician is stressed. 

The second paper deals with the impor- 
tance of the doctor-patient relationship, 
pleads for individualism in the practice of 
medicine, and tells how to win and to keep 
the patient's confidence. In the third paper, 
due tribute is paid the laboratory, but the 
point is emphasized that even now the num- 
ber of tested and reliable laboratory pro- 
cedures is relatively small, and that a 
thorough knowledge of a few methods is 
worth more to the clinician than a superficial 
acquaintance with many. 

The final essay is a letter to Dr. Long- 
cope, of Johns Hopkins, in which Dr. Pea- 
body sets forth his conception of the rela- 
tionship and responsibility of the Medical 
Chief to his Clinic. Only a real doctor and 
a true lover of humanity could have written 
it. No doctor could read it without wanting 
to do better work ; no teacher, without tak- 
ing a greater interest in his pupils; no medi- 
cal chief, without a more kindly feeling 
toward his patients and his interns. 

The first three papers should be required 
reading for third and fourth year medical 
students, interns, residents, and, so far as 
])ossible, practitioners. The fourth should be 
read at least once a year by every medical 



teacher and every attending i)h\sician in the 
country. The four together, if they could be 
assimilated into the professional souls of all 
the doctors in the country, would so raise 
the standards of practice as to put an end 
to all threats of political medicine. 

Reading this little classic is made i)oignant 
by knowing that its author died of cancer 
the day after finishing "The Soul of the 
Clinic". After one has read these four es- 
says, it is easy to agree with Dr. Hans Zins- 
ser's appraisal of their gifted author, in the 
foreword: "It is a rare blending of learning 
and humanity, incisiveness of intellect and 
sensitiveness of the spirit, which occasional- 
ly come together in an individual who 
chooses the calling of Medicine ; and then we 
have the great physician." 

* * :>: * 

SPOOL COTTON AS A SUTURE 
MATERIAL 

In the Juinnul of the Aiiivricaii Medical 
Anfiociation for December 16, (pages 2230- 
1), Drs. William H. Meade and Alton Ochs- 
ner, of New Orleans, strongly recommend 
ordinary spool cotton as a suture material. 
They have found that it has a number of 
advantages, other than the cost, over silk, 
linen, and catgut: It is less irritating to 
tissues; its tensile strength after implanta- 
tion shows no decrease until the tenth day 
or later, whereas other suture materials 
rapidly weaken ; it gains rather than loses 
strength in boiling; and its knot holds bet- 
ter. 

Drs. Meade and Ochsner use No. 60 plain 
cotton to ligate small vessels. No. 30 for 
approximating the peritoneum and fascia, 
No. 20 for retention sutures, and No. 10 
mercerized crochet cotton for through and 
through sutures of the abdominal wall. 
"Skin closure, when tension is not a factor, 
can be readily acomplished with No. 50 black 
mercerized thread. Black is used in.stead of 
white because the latter is somewhat diffi- 
cult to find at times, owing to its becoming 
stained with blood." 

While even the universal use of spool cot- 
ton by surgeons would not reduce the sur- 
plus cotton croi) stored in southern ware- 
houses as would the hypothetical extra inch 
on every Chinaman's shirt tail, it would seem 
to be almost an ideal suture material. Cer- 
tainly jt merits a trial. 



Kebiuaiy, 1940 



EDITORIALS 



lU 



A MESSAGE TO THE MEDICAL 
SOCIETY OF THE STATE OF NORTH 

CAROLINA FROM THE AUXILIARY 
THROUGH ITS PRESIDENT 

May I congratulate the Medical Society 
upon its establishment of a State Medical 
Journal ! A finer, more progressive group of 
doctors cannot be found than those here in 
North Carolina, and as an auxiliary we are 
proud that these outstanding men will have 
a channel for exchanging ideas that will 
I work for their enrichment and, thereby for 
the benefit of the people. 

The Journal is most fortunate in its capa- 
ble editorial staff. The Auxiliary is anxious 
to uphold this Editorial Board and cooperate 
with them in every way possible. 

May I here express the gratitude of the 
Auxiliary to the Medical Society of the State 
of North Carolina, for printing the 1939- 
1940 records of the Auxiliary, and also ex- 
press our appreciation for space set aside 
each month in this Journal for our use. 

We do want to justify our existence and 
your faith in us. We feel that we have your 
local support for many reasons, but especial- 
ly because: 

1. It was a doctor who asked for this aux- 
iliary and was responsible for its birth 
in 1923— Dr. John Wesley Long. 

2. The immediate past president, Dr. J. 
Buren Sidbury, in his message to the 
auxiliary from the Medical Society, 
complimented the auxiliary on its edu- 
cational and legislative work during his 
administration and commended to us a 
definite piece of work. 

3. Dr. Olin West of the American Medical 
Association, through Dr. Webb Griffith 
of Asheville, has asked us as an organi- 
zation to tell the public in every pos- 
sible way that should the Wagner Bill 
or its substitute become law, it would 
not be to the best interest of the doctor 
or the public. 

4. And finally, one doctor this year is 
especially anxious that an auxiliary be 
formed in his county while he is presi- 
dent of the County Medical Society. 

There is one thing the Auxiliary does want 
ihe Medical Society to know. Because we 
|as an auxiliary are anxious to be helpful to 
he Medical Society as well as to become 
letter doctors' wives for having been Aux- 
liary members, our activities are always 
aided by the Advisory Board which the 



Medical Society elects. The Auxiliary never 
sponsors or undertakes a main project with- 
out first getting the approval of this Ad- 
visory Board. Our Auxiliary By-Laws re- 
quire this guidance from the Medical Society 
as shown in Article II, Section 1 : 

"Objects. — The objects of this organiza- 
tion shall be to interpret the aims of the 
medical profession to other organizations in- 
terested in the promotion of health educa- 
tion ; to assist in the entertainment at the 
meetings of the Medical Society of the State 
of North Carolina ; to promote friendliness 
among the families of the medical profes- 
sion ; and to do such work as may be ap- 
proved from time to time by the Advisory 
Committee appointed by the Medical Society 
of the State of North Carolina." 

Again we thank the State Medical Society 
for its generous and loyal support of the 
Auxiliary. 

(Signed) Anna L. Stro.snider. 

THE WOMAN'S AUXILIARY 
For Mrs. Strosnider's gracious me.ssage to 
the Medical Society of the State of North 
Carolina, the North Carolina Medical 
Journal, as the official representative of the 
Society, makes its best bow. We doctors ap- 
preciate more than the Engli.sh language will 
allow us to say, the loyalty and cooperation 
of the Woman's Auxiliary. This organiza- 
tion of doctors' wives long ago justified its 
existence, and richly deserves the space al- 
lotted to it in each month's issue of this 
journal. Indeed, the North Carolina Medi- 
cal Journal belongs to the Woman's Auxili- 
ary as well as to the Medical Society of the 
State of North Carolina; for the Auxiliary 
is an integral part of the Society. 

Only too seldom are compliments ex- 
changed between husbands and wives. Mrs. 
Strosnider has set the example ; let us re- 
solve that in the future we will show more 
appreciation of our wive.s — both as individ- 
uals and as the organization known as the 
Woman's Auxiliary. Dr. Rock Sley.ster, in 
an address to the Milwaukee Woman's Aux- 
iliary, has well said that "Nothing is as im- 
portant in shaping the doctor's career as is 
his wife and his home. The doctor's wife 
must share his idealism, appreciate a stand- 
ard of values held by no other group, and 
give to him an understanding required of 
few. Being a doctor's wife is both an art 
and a career." 



112 



NORTH CAROLIN'A MEDICAL JOURNAL 



February, 1940 



CASE REPORTS 



TULAREMIA 
Report of a Case of the Oculo-Glandular Type 

B. W. Fassett, M.D. 
Durham 

Tularemia is primarily a fatal bacteremia of wild 
rodents; secondarily, a disease of human beings. 
In nature, it has thus far been found in ground 
squirrels, wild rabbits, rats and mice. It is trans- 
mitted to man by the bite of an intermediate host 
such as the horse fly, wood tick, bed bug, or flea. 
It may also be transmitted by the bite of a con- 
taminated animal, through self inoculation, or 
through contamination of the hands or conjunctival 
sac with parts of the internal organs' or body fluids 
of an infected animal. Therefore, it is more com- 
monly found in persons handling these animals — 
such as farmers, market men and women, cooks, 
hunters and laboratory workers. There is no record 
of the transmis-sion of the disease directly from 
man to man. 

The incubation period varies from one to ten 
days, with an average of three and a half days. 
The onset is sudden, and u,-iually consists of head- 
ache, chills and fever, aching, body pains, and 
sweating. In some cases nausea, vomiting, abdom- 
inal cramps' and diarrhea may be present. There 
is enlargement and tenderness of the regional lymph 
glands. The disease runs a rather prolonged course 
of two to eight weeks with remissions: of tempera- 
ture, recurring chills and sweats, loss of weight, 
weakness, and even prostration. Convalescence is 
slow, and there is great weakness on exertion; re- 
covery may take place in one to twelve months. 
Relapses of fever after eight to ten months, last- 
ing from six to eight days, have been reported. One 
attack, however, confers immunity. 

The oculo-glandular type presents multiple, small 
di.screte ulcers of the palpebral conjunctiva with 
yellow, necrotic plugs and indurated margins. There 
is marked chemosis and swelling of the lids with a 
mucoid discharge. In rare cases the bulbar con- 
junctiva is involved; single ulcers four or five mm. 
in diameter have been seen on the bulbar con- 
junctiva. Corneal complication.'; are rare. The re- 
gional lymph glands are swollen and tender. White 
cells are moderately increased, but the blood count 
is of no diagnostic importance. 

The diagnosis is made from the agglutination of 
the B. Tularense by the patient's blood serum. This 
reaction is absent during the first week, but appears 
during the second. 

Prevention is of major importance; after the 
disease is once established the treatment is purely 
symptomatic. At the piesent time a specific serum 
is being used with considerable success. 
Report of Cafse 

The ca.se I wish to report is that of a colored boy, 
ten years of age, from the northern part of Person 
C'ounty, who was admitted to Lincoln Hospital, Dur- 
ham, N. C, on June 27, 19:!6. 

The history of the ca.sc, taken by the intern, is as 
follow.s': In "the middle of June a wild rabbit was 
killed near the home. The animal was skinned near 
the house and the hide was left on the ground for 
several days. About five days later the boy's eyes 
became red, painful, and running. An epidemic of 
pink eye was present in the neighborhood, and the 

Read before tlie Section nn Opllial[nolop>' .and OlolaryliKoloey 
at llie Bermuda .Meetlcig uf the .Medical Society of the Slate 
of N'urib Carolina, .May IS, 193S. 



condition was attributed to that. Eye drops were 
obtained from a druggist, but the condition of the 
eyes showed no improvement. 

About a week later, another rabbit was caught 
and skinned by the boy's father. The dressed rab- 
bit was given to the boy to carry into the house. 
Next day the child complained of soreness about the 
ears. Both sides of the neck became swollen and 
the eyes so swollen that the child was unable to 
open them. The family physician was called and 
hospitalization was advised. 

The patient gave a history of having had the 
usual childhood diseases — measles, whooping cough 
and chicken pox. His health was always good ex- 
cept for frequent colds with sore throat and tonsili- 
tis. Family history was negative. 

I saw the patient the second day after he was 
admitted to the hospital. The temperature was 103, 
pulse 120, respirations 25. Urinalysis was negative, 
Wasserman plus one. A smear from the eye showed 
numerous pus cells. One smear showed staphylococ- 
cus. Examination of the blood showed red cells 
4,650,000, white cells 13,150, hemaglobin 80. Blood 
cultures were persistently negative. An agglutina- 
tion test for tularemia -was negative on the twelfth 
day, but positive on the fourteenth day. 

The appearance of the face and neck was that of 
combined gonorrheal ophthalmia and mumps. The 
eyes were closed by the intense swelling, and the 
lower lid was bathed in muco-pus. The glands of 
the neck were greatly swollen and tender. The 
everted lid revealed the typical picture of tularemia 
conjunctivitis. On each tarsal cartilage of the upper 
lid were ten openings that had the appearance of 
having been made with the corneal trephine, and 
each opening was filled with necrotic tissue. On 
the conjunctiva of each lower lid there were three 
of these ulcers, but they did not have the clear cut 
edge of those appearing on the upper lid. The re- 
semblance to the appearance of the tonsils in fol- 
licular toiisilitis was very striking. At no time was 
there any corneal involvement. 

As previously stated, the patient's temperature on 
admisiiion was 103, and for the first six days it re- 
mained at about this point, with very little varia- 
tion. On the seventh and eighth day there was a . 
distinct remission, the temperature reaching normal. 
On the ninth day there was recurrence of the fever, i 
which then reached the highest point during the 
sickness. For the next few days the temperatirre ] 
was of the septic type, but there was no s'uppuration i 
of the enlarged glands. There followed a gradual 
improvement in the patient, and he was discharged 
at the end of the third week with normal pulse and 
temperature; swelling of the glands was nearly 
gone, and the conjunctival lesions were healed. 

The general treatment was symptomatic and sup- 
portive. The eyes did best with instillation of 
argyrol every three hours, followed by boric acid 
wash. 



Comment 

This boy probably had an ordinary pink eye in 
the beginning, and by rubbing the eyes after hand- 
ling the dressed rabbit, he got a direct tularemia 
infection of the conjunctiva. If the fatlicr was cor- 
rect in the dates, the incubation period was only 
one day, which is frequently the case in severe in- 
fections. If he had received the infection when the 
first rabbit was killed, there would have been a 
positive agglutination the first week he was in the 
hospital. 

The interesting points in the case were the sud- 
denness and severity of the infection, the greatly 
enlarged glands, the typical punched out lesions of 
the conjunctiva, high temperature with prostration, 
and the remission with return of temperature. 



Februaiy, 10-10 



CASE REPORTS 



113 



In the community from which this boy came a 
number of cases of tularemia have been reported in 
the last two years. One terminated fatally. 

Abstract of Discussion 

DR. J. R. Mccracken (Waynesvllle): Do the 
eyes usually become affected in general tularemia? 

DR. FASSETT: Not necessarily. 

DR. J. D. FREEMAN (Moffitt); Have you had 
cases from the use of dyes on the eyelid? 

DR. FASSETT: 1 have never seen anything simi- 
lar to ciliary conjunctivitis. 

DR. PEELER: Did you say how many cas'es of 
that had been reported? 

DR. FASSETT: I do not know how many have 
been reported. This is the only one I have had. 
There have been a number reported in this country. 
There are quite a number in the literature. 

CHAIRMAN PEERY: Those ulcers do not have 
to be typically round and punched out. 

DR. FASSETT: They were irregular on the 
lower lid; pointedly regular on the upper. 

CHAIRMAN PEERY: There is some diversity 
in the shape of the lesions. Some of them aie 
rather irregular. Later in the disease they slough 
out, and are not so regular in their shape and size. 

I remember I had one case that looked as if the 
whole lower lid was going to slough all the way 
through — a late case when it was seen. I think 
most of the cases I have heard reported stressed 
that fact. Any unusual ulceration in the conjunctiva 
and the history is sufficient to make the diagnosis 
fairly certain, is it not? The blood reaction cinches 
the diagnosis. 

DR. FASSETT: That makes the diagnosis almost 
certain. 

DR. FREEMAN: You didn't use anything but 
argyrol and boric acid solution? 

DR. FASSETT: We tried several different things, 
but the eyes seemed to do better on using ten per 
cent argyrol. 



A NOTE ON NEURALGIAS OF 
CRANIAL NERVES 

Frederic M. Hanes, M.D. 
Durham 

Tic douloureux, or trigeminal neuralgia, is by far 
the commonest of the painful, paroxysmal cranial 
nerve neuralgias; but tic douloureux due to disease 
of the geniculate ganglion of the seventh nerve, 
causing geniculate neuralgia, and lesions of the 
petrous ganglion of the glossopharyngeal, or ninth 
nerve, producing glossopharyngeal neuralgia, are 
seen occasionally. 

Geniculate neuralgia is a frequent accompaniment 
of the common form of facial paralysis, or Bell's 
Palsy, causing pain behind the ear which may be- 
come severe, spreading to the front of the ear and 
dovra the neck. Geniculate herpes zoster, with vesic- 
ulation and great pain within the ear and concha 
is seen now and then, either alone or accompanying 
Bell's Palsy. 

Glossopharyngeal neuralgia, though rare, produces 
such a characteristic syndrome, and is susceptible 
to such brilliantly successful treatment, that it 
.should bo familiar to all. There follows a brief 
history of such a case: A married woman of .39 
came in February 1935 complaining of frequent at- 
tacks of sharp, stabbing pain in the left side of the 
throat and left ear. 

Nothing in her family or past histories shed any 
light on the present Illness. 

During the past three winters, beginning in Janu- 
ary, she has suffered from attacks of "sharp, quick 



pain", beginning in the left tonsillar region and 
passing upward to the left ear. The pain in the ear 
is of only a few seconds duration but while it lasts 
the ear "feels as though it would burst". "It is' a 
glimmering, sickening pain deep down in the center 
of the ear." The pain always comes in sharp at- 
tacks, sometimes one, again .several in quick suc- 
cession. She does not have these attacks in sum- 
mer, only in the cold winter months. Drinking cold 
water will "trigger" an attack and, recently, swal- 
lowing anything precipitates a seizure. She states 
that frequently thirty minutes or more are required 
to eat a simple breakfast. Fear of the attacks has 
causer her to limit greatly her food intake. 

Two wisdom teeth were removed 18 months ago, 
in the hope of relieving the paroxysmal seizures, 
and 13 months ago the tonsils were removed. No 
relief whatsoever was experienced following these 
operations. Recently the attacks have been more 
severe than ever. She has never had otitis media 
or ear-aches of the usiial variety. 

Physical examination revealed absolutely nothing 
which might be incriminated as a cause for the at- 
tacks; she was an exceptionally normal, healthy 
woman. Audiograms showed quite normal hearing. 

It was obvious that the patient's symptoms were 
due to "glossopharyngeal neuralgia", due to lesion 
of the petrous ganglion, the pain radiating mostly 
to the tympanic plexus of the tympanum, and she 
was placed on daily inhalations of trichlorethylene. 
The result was quite satisfactory. Within six weeks 
she was free of the attacks and during the following 
winter, which was one of exceptional severity, she 
had no attacks at all. She has been observed close- 
ly during the past four winters and no return of 
the seizures has occun-ed. 

Trichlorethylene inhalations were used in this 
patient with excellent results. The ampule was 
broken on a cotton sponge and inhaled through the 
mouth and nose three times daily. Its u.s'e was sug- 
gested by the occasionally successful treatment of 
trigeminal neuralgia with trichlorethylene. At the 
time, I could find no reference in the literature to 
its use in glossopharyngeal neuralgia, but a few 
months later Hoover and PoppenU) published an 
excellent review of the subject, and reported two 
cases successfully treated with trichlorethylene. 

Glossopharyngeal and trigeminal nem-algias may 
occur in eombination<2). 

Unfortunately we cannot hope that glossopharyn- 
geal neuralgia will yield very often to treatment 
with trichlorethylene, but fortunately Adson(3) has 
devised a relatively simple and safe operation for 
its cure. The ninth nerve is exposed and sectioned 
through a sub-occipital craniotomy, thus relieving 
permanently all the symptoms. 

CLINICO-PATHOLOGICAL 

CONFERENCE 

City Memorial Hospital 

Winston-Salem. 

Ca.se No. 1, Mr. R. C. S., a white male about 4B 
years of age, entered the hospital with pain in the 
back, weakness, fever and chills of two weeks' dura- 
tion. The patient dated the onset of his present 
illness to two years before admission, at which time 
he had had "muscle pains" running along both sides 
of his spine in the upper lumbar and lower thoracic 
region. This was accompanied by fever, weakness, 
and occasional chills. These attacks had recurred 

(1.) Hoover, W. B. anil I'uppen. J. L. : Cilo.Hsoplmiyiigeal 
Neuralgia. J. A. M. A. 107:1(115 (Sept.) I9;it;, 

(2.) Peet. M. M. : Glossopharyngeal Neuralgia. Ann, Surg. 
101: 230 (.Ian.) 1935. 

C;i.) Adson, A. W.: The Surgical Treatment of Glossopharyn- 
geal Neuralgia. Arch. Neurol, & Psychiat. 12:487 (Nov.) 
1824. 



114 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



at intervals of three to four months. The present 
attack was similar to these previous attacks'. The 
patient did not stop working- until two days before 
he was admitted, having had two or three chills 
while still at work. The patient had also had a 
sensation of pain immediately beneath the xyphoid 
process, and stated that food' did not seem to pass 
this area of his stomach until about three hours 
after meals. He was nauseated, but it was im- 
possible for him to vomit. 

Past history and the family history were negative 
except for a skull fracture four years: ago, and 
pneumonia. He denied venereal disease. 

PHYSICAL EXA.MINATION: Revealed a well 
developed and somewhat obese white male who 
was restless and slightly dyspneic, and appeared 
acutely ill. Examination of the head was negative 
except for pyorrhea and many carious teeth. The 
pharynx was reddened. CHEST: Respiration was 
somewhat labored, but expansion was equal. There 
was an area of tenderness over the right costal 
cartilages just below the xyphoid process. The 
lungs were clear to percussion and auscultation. 
HEART: Blood pressure was 105/60. Position of 
maximum impulse was' not palpable. The rhythm 
was regular, and rate was 110. There was a soft 
systolic murmur at the apex, which was trans- 
mitted over the entire precordial area. There was 
no thrill palpable. ABDOMEN: There was no ten- 
derness, and no masses or viscera were palpable. 

On admi.s'sion temperature was 101.2°, pulse, 116 
and respiration 22. 

LABORATORY WORK ON AD.MISSION: 

Urine: Showed a trace of albumin and 3-5 hyalin 
casts. 
Blood: 

R. B. C. 5,200,000 

W. B. C. 11,000 

Stabs. 16% 

Segs. 46% 

Lymphs. 36% 

Monos. 2','v 

Hb. 17 grams 

There were no malarial parasites present. 
Smears from the gums showed staphylococcus. 

Seven days' after admission the patient developed 
dullness at the left lung base with a few rales in 
both ba.ses. The heart .sounds were of poor quality, 
with no change in the heart murmur. The eye 
grounds showed indistinctness of the margins of 
the discs, with a recent flame-shaped hemorrhage 
pres'ent at the temporal side of the right disc, and 
slight arterio-venous compression. The blood pres- 
sure at this time was 80/50. The patient began to 
cough, and had showers of rales over the anterioi 
portion of the right chest, with a few rales at the 
left base and in the left axilla. X-ray examination 
revealed a patchy consolidation at the left upper 
lobe and the right middle and lower lobes; the 
heart was markedly enlarged in the tran^erse and 
long diameters. The patient's condition grew steadi- 
ly worse. The heart became irregular, and the 
blood pressure remained extremely low. The physi- 
cal signs in the chest increased until the patient 
died twelve days after admission. The urine showed 
a trace of albumin throughout the stay in the hos- 
pital, with hyalin and granular casts present. The 
sputum showed staphylococci and streptococci. The 
blood cultures were negative. Cultures for typhoid 
fever were negative. Agglutination for typhoid. 
Brucella Abortus, B. Proteus X 19, B. tularense and 
B. para typhosus A. and B. were negative. The red 



count remained over four and a half million. The 
white count remained between fourteen and seven- 
teen thousand with a moderate increase of poly- 
morphonuclears. The stools were negative for para- 
sites and ova. The sputum was negative for tubercle 
bacilli. The temperature continued elevated through- 
out the course, ranging between 101' F. and 103°F. 
The pulse ranged between 100 and 120. Respira- 
tions increased from 22 on admission to 45 on the 
day before death. 

CLINICAL DISCUSSION: This case presents 
the picture of an obese white man of 46 who died 
apparently of pneumonia. The fact that he was ill 
for two years with recuiring chills, fever, and pains 
in the back leads one to suspect a renal lesion such 
as pyelitis, pyelonephritis, or multiple intracapsular 
or subcapsular abscesses. At any odds, he seems 
to have had some chronic low grade pyogenic infec- 
tion for two years.. His' terminal illness for which 
he was admitted to the hospital took its onset as 
the other episodes had done, but was more severe 
and was climaxed by pneumonia and death. 

The findings of marked cardiac dilation, a heart 
murmur, and finally of a petechial hemorrhage in 
the retina, point definitely toward bacterial endo- 
carditis". There should be embolic lesions in the kid- 
neys, spleen, and other viscera. 

It is difficult to conceive of this man's clinical 
picture as being at all typical of subacute bacterial 
endocarditis, as there was no wasting, anemia, or 
evident pre-existing rheumatic valvular oi' congeni- 
tal heart disease. It s-eems the conservative thing 
to say that he had bacteremia and likely acute en- 
docarditis of short duration, with death due to 
pneumonia and heart failure. 

A point to bring out here is that if one has 
reason strongly to suspect bacteremia, repeated 
blood cultures should be performed, the blood being 
drawn while the temperature is down as well as 
during its height following chill.s'. Most bacteria 
are definitely attenuated by heat, and so might be 
grown more easily if cultured from media of nor- 
mal body temperature. The case in point had only 
one blood culture, which showed no growth. Some 
sti'ains of streptococcus viridans are grown with 
great difficulty and only after many attempts with 
various culture media. Some are even anaerobic. 

Pain in the back has been found in my experience 
to be a very common accompaniment of bacterial 
endocarditis, but the pain in this case seem.s' not to 
have been caused by this disease, or the clinical 
picture would have manifested itself in two years 
time. 

AUTOPSY: The autopsy showed an acute bac- 
terial endocarditis with complete destruction of two 
of the aortic leaflets, and a large mass- of vegeta- 
tions in one of the sinuses of valsalva, which ex- 
tended through the wall of the sinus and projected 
into the cavity of the right auricle just above the 
tricuspid ring. There was red hepatization of both 
lungs, and a thrombus in a small pulmonary artery 
in the left lower lobe. Staphylococci were obtained 
from the vegetations in the heart. 

DISCUSSION: Autopsy .showed a case of an 
acute ulcerative bacterial endocarditis caused by 
the staphylococcus, with early consolidation of the 
lungs. The presence of severe pyorrhea, with 
staphylococci from the gums, suggests that the site 
of origin of this endocarditis wa.s- the pyorrhea. 
The history of muscle pain in the back may well 
have been also a result of the pyorrhea, with tran- 
sitory invasion of the blood stream by organisms. 
There was no anatomrical explanation for the dis- 
comfort in the epigastrium. 



Febi-uaiy. 1940 



BULLETIN BOARD 



115 



BULLETIN BOARD 



NOTES FROM THE OFFICE OF THE 
SECRETARY-TREASURER 

There have been numerous inquiries from 
physicians in the twenty unorganized coun- 
ties as to the proper procedure in joining 
the State Society. Under our Constitution 
and By-Laws a choice is given : they may 
send their annual dues of $8.00 direct to this 
office; or, they may join any adjoining or- 
ganized County Society and send their dues 
through its secretary. 

;;; * * * 

The Duplin County Medical Society has 
been reorganized with Dr. B. B. McGuire of 
Kenan-sville as Secretary. 

^: :;: * :;: 

Membership in the House of Delegates is 
based on the ratio of one delegate for each 
25 members. The County Societies are urged 
to send in correct names and addresses of 
all delegates prior to March 1, thereby .sav- 
ing the usual loss of time and confusion in 
organizing the House of Delegates at the 
annual meeting. This is to be held in the 
Carolina Hotel, Pinehurst, May 13, 14, and 
15. 

T. W. M. Long, M.D. 

Secretary-Treasurer. 



American Board of Obstetrics and 
Gynecology Examinations 

The general oral and pathological examinations 
'Part ll> for all candidates (Groups A and B) will 
be conducted by the entire Board at the Atlantic 
City Hospital, Atlantic City, N. J., from Friday, 
June 7, through Monday, June 10, 1940, prior to the 
opening of the annual meeting of the American 
Medical Association in New York City on Wednes- 
day, .Tune 12, 1940. Candidates are requested to 
note that the dates of the examinations have been 
advanced one day from those previously announced. 

Applications for admission to Group A, Part II, 
examinations mu.<^: be on file in the Secretary's 
Office not later than March 15. 1940. 

Formal notice of the time and place of these ex- 
aminations will be sent each candidate several weeks 
in advance of the examination dates. 

Candidates for reexamination in Part II must 
make written application to the Secretary's Office 
before April 15. 

The annual dinner of the Board will be held in 
New York City on Wednesday evening, June 12, 
1940, at the Hotel McAlpin. For further infoiTiia- 
tion and application blanl<s, address Dr. Paul Titus, 
Secretary, 1015 Highland Building, Pittsburgh, 
Pennsylvania. 



South Atlantic Association of Obste- 
tricians AND Gynecologists 

The Annual Meeting of the South Atlantic Asso- 
ciation of Obstetricians and Gynecologists was held 
at the Jefferson Hotel in Richmond, February 9 and 
10. The program was as follows: 

Friday, February 9 

9:30 A.M.: 

R. T. Ferguson, Charlotte, N. C. 

"A Review of the Data on 600 Women Tested 
for Patency of the Fallopian Tubes". 
Discussants: 

1. F. Richards, Jacksonville, Fla. 

2. Kemiit Brown, Asheville, N. C. 
J. Randolph Perdue, Miami, Fla. 

"The Postpartum and Postoperative Bladder". 
Discussants: 

1. Manley Hutchinson, Columbia, S. C. 

2. H. H. Ware, Richmond, Va. 

Guest Speaker: Phillip Williams, Phila- 
delphia, Pa. 
F. Bayard Carter, Durham, N. C. 

"Late Toxemias of Pregnancy with Analysis of 
Postmortem Findings". 
Discussants: 

1. R. A. Bartholomew, Atlanta, Ga. 

2. Joseph Baer, Richmond, Va. 
President's Address': Robert E. Seibels, Co- 
lumbia, S. C. 

6:00 P.M.: 

President's Party. Jefferson Hotel. 
7:00 P.M.: 

Banquet. Howard W. Blakeslee, Science Editor, 
Associated Press, New York, Speaker. 

Saturday, February 10 

9:30 A.M.: 

R. B. Greenblatt, Augusta, Ga. 

"The Estrogenic Activity of Dicthylstilbestrol". 
Discussants: 

1. E. C. Hamblen, Durham, N. C. 

2. T. J. Williams. Charlottesville, Va. 
R. B. Dunn, Greensboro, N. C. 

"Asphyxia Neonatorum". 
Di.scussants; 

1. W. A. Hart, Columbia, S. C. 

2. C. J. Collins, Orlando, Fla. 

Guest Speaker: Arthur Curtis, Chicago, III. 
Dr. G. R. Holdcn, Jacksonville, Fla. 

"The Use of Radium in Treating Menopausal 

Hemorrhages of Benign Origin". 
Discussants: 

1. W. R. Payne, Newport News, Va. 

2. J. D. Parker, Greenville, S. C. 
Dr. C. J. Andrew.^ Norfolk, Va. 

"The Third Stage of Labor with a Description 
of a New Method of Expression of the Placenta" 
Di.scussants: 

1. Hunter Jones, Charlotte, N. C. 

2. O. R. Thompson, Macon, Ga. 



American Academy of Pediatrics 

The District of Columbia members of the Ameri- 
can Academy of Pediatrics will be hosts for the 
Annual Meeting of Region 1 of the American Acade- 
my of Pediatrics on April 4th, 5th and 6th, 1940, 
at the Mayflower Hotel, Washington, D. C. 



116 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 




Architect's sketch of a bird's-eye view of the Hdw man Gray School of Medicine, and enlarg:ed North 
Carolina Haptist Hospital in AVinston-Salem as it will appear after completion. In the foreground is the 
new wing to be added to the present hospital and also shown is the four-story addition to be constructed 
on the south end of the hospital. At the right is the medical school building which will be directly con- 
nected on all floors with the hospital. Total cost of the hospital addition and the medical school, affiliated 
with A\'ake Forest College, together with equipment, will be approximately $750,000.00. 



Bowman Gray School of Medicine 
OF Wake Forest College 

Plans for the con.-<truction of the Bowman Gray 
School of Medicine of Wake Forest College and for 
the enlargement of the North Carolina Baptist Hos- 
pital are rearing completion, and it is thought that 
work on the building will begin around June 1. 

The medical school building will be constructed 
across the north end of the present hospital, directly 
adjoining it. The hospital itself will be tripled in 
b-izc by the addition of two wings — one at the rear, 
six stories high, and the other at the south end of 
the building, four stories high — and by the enlarge- 
ment of the kitchen wing. Among the features of 
the medical school, which will be large enough to 
accommodate a maximum of 50 students in each 
class, will be an auditorium with a seating capacity 
of 300 and a library with a 50,000 volume capacity. 
In the enlarged hospital an ampitheatre with 100 
seats will be built next to the operating room. Two 
floors of one wing will be given over to pediatrics". 

Although the medical school and hospital will be 
separately owned and financed, they will be served 
by a joint professional staff. The school expects to 
cooperate with all other medical institutions in Win- 
ston-Salem and Forsyth County. 

The total expenditure on buildings and equip- 
ment will be about $750,000, $300,000 of which will 
go for the medical school building alone. Funds 
for the medical school are being provided by tho 
Bowman Gray Foundation. More than $200,000 has 
been subscribed throughout the state for the addi- 
tions to the hospital. 

Northup and O'Brien are the architects. 



News Notes from Duke University 
School of Medicine 

On January 9 Dr. Charles L. Scudder, Fracture 
Surgeon, of Boston, Mass?., held a clinic for the staff 
and students on "Emergency Splinting of Fractures". 



Notes from the Division of Public 

Health, University of North 

Carolina 

Dr. Harold W. Brown. Professor of Public Health. 
is making a survey of the parasites of a representa- 
tive sample of the population of the state. He is 
making a special study of the problems of malaria 
and hookworm, and has recently published on tho 
subject: "A Survey of Intestinal Helminths in 
Orange County, N. C.." and "A Note of the Preva- 
lence of Intestinal Helminths in Orange County. 
N. C." 

Dr. Brown, in collaboration with Dr. James C. 
.\ndrews, Professor of Biological Chemistry in the 
School of Medicine, is studying the problem of the 
dis"tribution of quinine in the blood under various 
conditions, and other questions relating to the bet- 
tor treatment of malaria. 

Dr. William L. Fleming, formerly of the Johns 
Hopkins School of Medicine, has been added to the 
faculty of the Division of Public Health as Professor 
of Syphilology. He will continue research in syphilis 
and conduct special courses' in syphilology. 

Dr. Daniel F. Milam. Professor of Nutrition in 
the Division of Public Health, is making a study of 
the nutritional defects in this state. His studies 
will include both laboratory and clinical observa- 
tions on the dietary defects leading to vitamin defi- 
ciencies. 

Dr. Milton J. Rosenau is Chairman of a Board 
ai'pointed by Surgeon General Thomas PaiTan, of 
the U. S. Public Health Service, to report on the 
health hazards incident to use of city wastes in 
land-fill operations in Queens County, New York. 

Dr. Roy Norton, Professor of Public Health Ad- 
ministration, is making special studies on public 
health administration and government with refer- 
ence to health in the South. 

Dr. Herman G. Baity, Professor of Sanitary En- 
gineering, is making special studies of textile wastes, 
water purification, sewage disposal, etc. 

Professor H. B. Gotaas, of the Engineering Dc- 



February, 1940 



BULLETIN BOARD 



117 



j partment, is carrying on studies on the biological 
( oxidation of sewage wastes in fresh and sea water 
i at different temperatures, and on the control of 
1 algal growths on the walls of swimming pools. 

Profess'ors Baity and Gotaas, with the assistance 
' of Mr. Ralph Forges and Mr. Robert K. Horton, 
under a special grant from the Textile Foundation, 
are carrying on investigations on the control of tex- 
tile waste pollution. 

Dr. Albert .1. Sheldon, instnictor in public health, 
is working with Dr. Brown on the treatment and 
I [lideniiology of dog heartworm. Their studies on 
the treatment of these parasites are being conducted 
with the aim of finding a successful treatment for 
human hlariasis. 

A number of research scholars are engaged in the 
various departments of the Division of Public Health. 
Mr. Sidney F. Ascher, with the assistance of Mr. 
Abraham Rotman, is making a study of diptheria 
carriers; Mr. A. E. Williamson. Jr., is working on 
a study of bacterial air pollution and methods of 
ciintrol; Mr. Emil T. Chanlett is working on indices 
lor swimming pool safety; Mr. William A. Moggio 
is working on the fates of certain parasites in 
ilitFerent processes of sewage treatment; Mr. R. F. 
Hill, Jr., is working on the characteristics of in- 
stitutional and residential sewage; Mr. Thomas J. 
Brooks', Jr., is working on influenza; and Mr. Wil- 
liam W. Taylor, Jr., is working on the malaria and 
hookworm survey. 

The Division of Public Health offers one short 
(ourse each fall. It has seven full-time members 
on its faculty: Dr. Milton J. Rosenau, Dr. Herman 
<;icnn Baity, Dr. Harold W. Brown, Dr. J. W. Roy 
.\"(irton. Dr. William LeRoy Fleming, Dr. Daniel 
Franklin Milam, and Professor H. B. Gotaas, and 
enjoys the advantage of the cooperation of Dr. Carl 
\'. Reynoldi?, Secretary and State Health Officer of 
the N. C. State Board of Health, who gives a course 
in public health. 

The Division of Public Health now offers graduate 
(■nurses leading to the degrees of Doctor of Public 
Health, Doctor of Philosophy in Public Health, 
Master of Public Health, Master of Science (with 
disignation), as well as the Certificate in Public 
Health. 

Through the interest of Dr. V. Korenchevsky, of 
the Lister Institute of Preventive Medicine of Lon- 
don, an international club has been formed to study 
-■arious aspects of the proces.ses of ageing — "Club 
. For Research On Ageing". The American division 
of this Club met in Washington on January 12 and 
13 to effect an organization and proceed with dis- 
cussions and research projects which may throw 
light on various phases of the ageing process. The 
members of the Club are as follows: Professors 
W. A. Allen, of Washington University; W. Bauer, 
Harvard University; Walter B. Cannon, Harvard 
University; Alfred E. Cohn, Rockefeller Institute 
for Medical Research; E. V. Cowdry, Washington 
University; E. T. Engle, Columbia University; C. 
G. Hartman, Carnegie Institution of Washington, 
Johns Hopkins University; A. Baird Hastings, Har- 
vard University; F. L. Hishaw, Harvard University; 
K. S. Lashley, Harvard University; C. M. McCay, 
Cornell University; Wm. deB. MacNider, University 
of North Carolina; J. H. Means, Harvard Medical 
School; W. R. Miles, Yale University: R. A. Moore, 
Washington University; Jean Oliver, Long Island 
College of Medicine; Oscar Riddle, Carnegie Insti- 
tute, Cold Springs Harbor, Long Island; Vincent 
duVigneaud, Cornell University. 

The officers elected at this organization meeting 

were Wm. deB. MacNider, Chairman; R. A. Moore, 

Secretary. Executive Committee: W. B. Cannon, 

E. T. Engle and R. A. Moore. 

Tire American Division of this international club 



anticipates meetings in the future with similar clubs 
that have been organized in England, the Scandi- 
navian countries, and Continental Europe. It is the 
hope of such informal groups of investigators that 
they may be of mutual a.ssistance, and through such 
assistance advance research now in progress and 
projects which may be undertaken by various mem- 
bers of the different groups. 



State Board of Charities and Public 
Welfare 

After being without a Director for the Mental 
Hygiene Division for six months, the State Board 
of Charities and Public Welfare has appointed Dr. 
.1. Watson to that position. Dr. Watson graduated 
from the Northwestern University Medical School, 
and served an internship in a Chicago hospital, 
specializing in surgery. For ten years he was super- 
intendent and surgeon of a charitable hospital in 
Puerto Rico, and for his work in surgery therc^ was 
made a fellow of the American College of Surgeons. 
In 1934 he studied Neuro-psychiatry in Columbia 
University Post-Graduate Medical School. New York 
City, and later was on the staff of the Elgin State 
Hospital in Illinois. For the oast three years he 
has been on the staff of the Worcester State Hos- ' 
pital, Worcester, Mass., holding the position of 
Director of the Worcester Mental Health Clinic and 
Family Care Department. He is a diplomate of 
the American Board of Psychiatry and Neurology. 

Dr. Richard F. Richie was named Assistant Di- 
rector in charge of the Children's Unit. Dr. Richie 
is a graduate of the University of Buffalo College 
of Medicine. 1937. After a thorough grounding in 
Pediatrics, he served as Assistant Physician to the 
Harrisburg State Hosnital. Then he Was given a 
Commonwealth Fund Fellowship at the Child Guid- 
ance Clinic of Cleveland (twenty-two months). He 
came to North Carolina July 1, 1939, from Nebraska, 
where he was Staff Psychiatrist to the Child Wel- 
fare Division, Board of Control. Dr. Richie is a 
Fellow of the A. M. A. and a member of the Ameri- 
can Psychiatric Association, the American Ortho- 
ps.vchiatric Association, the International Associa- 
tion for Exceptional Children, and the American 
Association on Mental Deficiency. 



Southeastern Surgical Congress 

Dr. R. B. McKnight, Charlotte. N. C, Chairman 
of the North Carolina Division of the Southeastern 
Surgical Congress, makes the following announce- 
ment: 

The Southeastern Surgical Congress will hold its 
Eleventh Annual Assembly in BiiTningham. March 
11, 12, 13, 1940, at the Tutwiler Hotel. The com- 
pleted programs will be mailed out between the 1.5th 
of February and the first of March. Make plans 
to attend. For information, write Doctor B. T. 
Beasley, Secretary-Treasurer, 701 Hurt Building, 
Atlanta, Ga. 

1940 Program 

Birmingham Assembly of the Southeastern 

Surgical Congress 



Gynecology 

Dr. Quitman U. Newell, St. Louis: "Conunon 

Lesions of the Vulva, and Their Teatment." 
Dr. C. J. Andrews, Norfolk: "Pelvic Supports — 

Their Injury and Repair." 
Dr. Robert A. Ross, Durham: "Sex Endocrinology 

and Pelvic Surgery." 

Laryngology 
Dr. Edward A. Looper. Baltimore: "The Diagnosis 

and Surgical Treatment of Carcinoma of the 

Larynx." 



118 



NORTH CAROLINA MEDICAL JOURNAL 



February, 19-10 



Otology 

Dr. S. S. Hall, Clarksburg, West Va.: "Chronic 
Exuative Sclerosing Mastoiditis." 
Ophthalmology 
Dr. R. O. Rychcner, Memphis: "A Simple Technique 
for Glass Ball Implantation Following Enuclea- 
tion of the Eye Ball." 

Medicine 
Dr. James K. McGregor. Hamilton, Canada: "Dys- 
function of the Thyroid Gland as a Cause for 
Premature Old .■\gc." 
Dr. T. Z. Cason. Jacksonville, Fla.: Subject to be 

announced later. 
Dr. Francis M. Massie, Lexington, Ky.:_ "Amebic 

Colitis as a Cause of Abdominal Pain." 
Dr. K. K. Sherwood. Seattle: "Classification and 
Treatment of Chronic Arthritis." 
Proctology 
Dr. Martin S. Kleckner, Allentown, Pa.: Subject 

to be announced later. 
Dr. -Louis A. Buie. Rochester, Minn.: "Management 
of Anal Fistulas in Office and Hospital." 
.Vnaesthesia 
Dr. C. N. Caixaway, Birmingham: "Pentothal So- 
dium Oxygen Anaesthesia." 
Surgery 
Dr. Herbert Acutf, Kno.\ville: "The Surgical Treat- 
ment of Pulmonary Tuberculosis With a Survey 
of End Results." 
Dr. Russell B. Bailey, Wheeling. West Va.: "Surgi- 
cal Treatment of Obstruction at the Cardiac 
Orifice." 
Dr. Randolph L. Clark, Jackson, Miss.: "Recent 
Advances in the Management of Intestinal Ob- 
struction." 
Dr. George Curtis, Columbus, Ohio: "The Rationale 
of Splenectomy in the Treatment of Certain 
.Anemias." 
Dr. T. C. Davison. .A.tlanta: "Breast Tumors. Mov- 
ing Picture in Color." 
Dr. Michael de Bakey. New Orleans: "Significant 
Factors in the Prognosis and Mortality of Per- 
forated Ulcer." 
Dr. James W. Gibbon. Charlotte: "Gastro-Jejunal 

Ulcer with Case Reports." 
Dr. Stuart W. Hairington, Rochester, Minn.; "Surg- 
ical Treatment for Calcified Constricting Peri- 
cardium." 
Dr. Frank S. Johns, Richmond: "The Progress in 
the Development of Extrapleural Thoroplasty in 
the Treatment of Pulmonary Tuberculosis." 
Dr. J. B. Lukins-. Louisville: "Post-operative Pul- 
monary Complications." 
Dr. J. M. Mason. Birmingham: "C. Jeff Miller Me- 
morial Lectureship." 
Dr. Roy D. McClure, Detroit; "The Modern Treat- 
ment of Burns." 
Dr. Georee Pack. New York City: "The Diagnosis 
and Treatment of Malignant Tumors of the 
Skin." 
Dr. Edwin G. Ramsdell, New York City: "The Pre- 
vention of Wound Disruption." 
Dr. J. D. Rives, New Orleans: "The Splenic 
Aneni'as: Present Conception of the Etiology, 
Diagnosis and Treatment. With Some Sugges- 
tion on Surgical Technique." 
Dr. R. L. Sanders. Memphis: Presidential Address. 

Genito-Urinary Surgery 
Dr. Edgar G. Ballenger. Atlanta: "The Importance 
of Early Diagnosis of Genito-Urinary Diseases." 
Dr. Robert" Herbst. Chicago: Subject to be anounced 

later. 
Dr. Rov B. Henline, New York City: "Prostatic 
Disease With a Special Reference to the Various 
Causes and Types as well as Their Treatment." 



Dr. Nelse F. Ockerblad, Kansas City: Subject to 
be announced later. 

Dr. Lawrence P. Thackston, Orangeburg: ' Supra- 
public Prostatectomy With the Use of an Ongi- i 
nal Combination Hemostatic Drainage Bag." 
Orthopedic Surgery 

Dr. Austin T. Moore, Columbia; "The Treatment 
of Fractures- of the Neck of the Femur by In- 
ternal Fixation With Four Adjustable Nails— 
An End Result Study." 

Dr. Leslie V. Ru.sh, Meridian: "Some Commonly 
Seen Fracture Cases in which Bad Results Fre- 
quently Occur." 

Pediatric Surgery 

Dr. Stanley J. Scegar, Milwaukee: "Pediatric Surgi- 
cal Problems." 

Neuro-Surgery 

Dr. Cobb Pilcher, Nashville: "Surgical Aspects ot 
Epilepsy." 

Dr. Exum Walker, Atlanta: Subject to be announced 
later. 

North Carolina Neuro-Psychiatric 
Society 

The North Carolina Neuro-Psychiatric Society met 
in Charlotte on January 26. The following program 
was given : 

Afternoon Session 
"Extra-Mural Neuropsychiatry and Neuropsychiatry 
in a General Hospital"— Dr. R. S. Crispell, Dur- 
ham. 
"Neurological Heredity in North Carolina' — Dr. 

William Allan, Charlotte. 
"Frontiers in Psychological Medicine" — Dr. Ken- 
neth E. Appe!," Professor of Psychiatry, Univer- 
sity of Pennsj'lvania — Guest Speaker. 

Evening Session — Hotel Charlotte 
Social Hour— 5:45 P. M.— Lounge Room 
Dinner— 6:30 

Round Table Discussion: ".^cute Infections and 
Suppurative Conditions of the Brain and Spinal 
Cord— Sulfanilamide, etc."- Dr. Barron, Leader; 
Drs. Alexander, Adams, Motley, Hovis, Teasdale, 
Woodall, Leinbach, Hart, Baker, Ashe, Hunt, 
Robert Moore, and Selby. 
"Clinical and Pathological Discussion of Brain Tu- 
mors" — Dr. Edgar F. Fincher, Professor Neuro- 
surgery, Emory University — Guest Speaker. 
The officers of the society are: Dr. W. D. Hall, 
Raleigh, president; Dr. Mark Griffin, Asheville, vice 
president; Dr. Malcolm Kemp, Pine Bluff, secretary- 
treasurer. 

Statewide Syphilis Survey 

Out of 9.53.3 prisoners in eighty camps- who were 
given serological tests for syphilis in a statewnde 
survev conducted cooperatively by the State Board 
of Health and the North Carolina Highway and 
Public Works Commission, 2.229. or 23.3 per cent, 
were found to be syphilitic. The survey was maile 
with the aid of the Reynold? Foundation. 

The results, announced by Dr. Carl V. Reynold.-, 
State Health Officer, following conferences with 
prison officials, showed that 8.5 per cent of all white 
prisoners and 34.2 per cent of all Negro prisoners 
reacted positively to the tests. 

"The object in making this exhaus-tive survey. 
said Dr. Reymolds. "was to get that portion of our 
prison population infected with syphilis under com- 
petent treatment. Cooperative arrangements have 
been made wherebv the State Board of Health will 
furnish one-half the drugs, while the prison de- 
partment will meet the other half of the expense 
for this purpose." 



I'fhniaiy. 10411 



BULLETIN BOARD 



119 



COUNTY SOCIETIES 



Buncombe County Medical Society 

The Buncombe County Medical Society held two 
meetings in January in the Council Chambers of 
the City Hall. On January 15 Dr. Wm. Murray 
Hollyday delivered his Presidential Address, Dr. 
Samuel S. Looley presented a case of Cerebral 
Aneurysm, and Dr. J. T. Saunders reported a case 
of Slipped temoral Epiphysis. On January 22, Dr. 
K. C. Bunts gave a paper on "Congenital Obstruc- 
tion of the bladder iNeck", which was dis'cussed by 
Dr. VV. C. Lott. 'the otficers of the iiuncomDe 
County Medical Society for iy4U are; Dr. W. M. 
Hoiiyuay, president; ur. John T. Saunders, vice- 
president; Dr. U. W. kutscher, Jr., secretary. 



Forsyth and Guilford County 
Medical Societies 

On January 11 the Forsyth and Guilford County 
Medical Societies held a joint dinner meeting at 
the Smokehouse in Winston-Salem. The guest 
speaker was Dr. Foster Kennedy, frofes'sor of iNeu- 
rology at Cornell University. Dr. Kennedy spoke 
on "The Organic Background of Mind". 



Halifax County Medical Society 

The Halifax County Medical Society held its regu- 
lar monthly meeting Friday evening, January 12, 
at the Eoanoke Kapids Hospital in Roanoke Rapids, 
with Dr. W. G. Suiter, president of the society, 
presiding. 

Dr. Herman Farber and Dr. James Whitfield of 
Richmond, Virginia, presented papers on "Care of 
the Newborn Baby's Skin" and "Puerperal Sterili- 
zation", in which attention was called to the most 
recent developments in these fields of medical 
sx:ience. Dr. T. W. M. Long, Secretary of the 
State Medical Society, asked that the former article 
be submitted to the North Carolina Medical Journal 
for publication. 

Dr. Raleigh Parker of Jackson, Dr. R. B. Out- 
land of Rich Square and Dr. Robert F. Young, 
Health Officer of Halifax County, were admitted to 
the society. 

Following the scientific meeting, election of officers 
for the coming year was held, in which Dr. F. W. 
M. White of Halifax was elected president; Dr. C. 
B. Robertson of Jackson, vice-president; Dr. Robert 
F. Young of Weldon, secretary and treasurer; and 
Dr. W. G. Suiter of Weldon, delegate to the State 
Medical Society, with Dr. M. S. Broun as alternate 
delegate. 

Dr. Lupton, from the division of Child Hygiene 
of the State Public Health Department, was a visi- 
tor at the meeting. 

Under Dr. W. G. Suiter's able leadership the 
society has completed a very successful year in 
maintaining good attendance and in obtaining out- 
standing physicians to appear on the programs. 
Robert P. Young, M.D. 
Secretary and Treasurer 
Halifax County Medical Society. 



Rockingham County Medical Society 

At the January meeting of the Rockingham 
County Medical Society, held January 20 at the 
City Memorial Hospital in Reidsville, Dr. James W. 
McAnally of Reidsville was elected president. Other 
officers elected for 1940 were: Dr. Keenan Casteen. 
Leaksville, vice president; and Dr. W. A. Johnson. 
Reidsville, secretary-treasurer. Delegates to the 
state medical society are, Drs. B. F. Cozart and 
William Hester, with Dr. J. B. Ray and Dr. J. W, 
MeGehee as alternates. A paper was read by Dr. 
Newton G. Wilson, of Madison. 



News Notes 

At the twentieth annual New Y'ear meeting of the 
Marlboro County Medical Society, held in Bennetts- 
ville, S. C, on January 11, Dr. Robert A. Ross, 
Associate Professor of Obstetrics and Gynecology 
at Duke University, prevented a paper on "The 
Management of Prolonged Labor". Dr. Paul P. Mc- 
Cain, of Sanatorium, led in the discussion of a paper 
by Dr. W. Atmar Smith on "The Differential Diag- 
nosis of Pulmonary Tuberculosis". 
***** 

The Third Annual Session of the Atlanta Gradu- 
ate Medical Assembly was held January 15-18 at 
the Biltmore Hotel in Atlanta. Among the speakers 
was Dr. Watt W. Eagle, Associate Professor of 
Surgery at the Duke University School of Medicine, 
who spoke on "Sphenopalatine Neuralgia." 

* * * * 

At the annual meeting of the Birth Control Fed- 
eration of America, held in New York on January 
25, Dr. Carl V. Reynolds was named on the Na- 
tional Committee for Planned Parenthood, which is 
to sponsor a nation-wide campaign for birth control. 
Margaret Sanger is chairman of the committee. Dr. 
Roy Norton of the University of North Carolina 
discussed "Planned Parenthood in a General Health 
Program" before a symposium on "Race Building 
in a Democracy". North Carolina has the first 
state-sponsored birth control program in the Union. 

* * * * 

Dr. Irving E. Shafer has been elected Chief of 
Staff of the Rowan Memorial Hospital, succeeding 
Dr. James C. Eagle. Other officers elected for 1940 
were Dr. Walter L. Tatum. Assistant Chief of Staff, 
and Dr. T. W. Seay, secretary. 

* * * * 

Dr. I. E. Shafer, of Salisbury, and Miss Jane 
Honeycutt, of Franklinton, were married in New 
York on January 16, at "The Little Church Around 
the Corner". 



Resolution Adopted by the Forty-First 

Annual Convention of the National 

Association of Retail Druggists 

WHEREAS, since the comparatively recent dis- 
covery and developments of vitamins, many avenues 
of distribution such as mail order houses, grocers, 
etc., are selling such vitamins, and 

WHEREAS, the sale by such outlets is detriment- 
al to public welfare; therefore, be it 

RESOLVED, that in the interest of public health 
the sale of such products should be restricted to 
drug stores, and be it further 

RESOLVED, that until such time as proper safe- 
guards to circum.scribe the sale of vitamin products 
can be promulgated, the N.A.R.D. specifically re- 
quests vitamin manufacturers to restrict their sale 
to drug channels, and be it further 

RESOLVED, that a copy of this resolution be 
sent to the American Medical Association and to 
all state medical societies. 



120 



NORTH CAROLINA MEDICAL JOURNAL 



Febiuarv, 1940 



Officers 

President: Mrs. C, F. Strosnider, Goldsboro. 

President-Elect: Mrs. C. R. Hedrick, Lenoir. 

Chairman of Past Presidents: Mrs. P. P. McCain, 
Sanatorium. 

Correspondinfr Secretary: Mrs. Jack Harrell, Golds- 
boro. 

Recording Secretary: Mrs. J. D. Freeman, Wil- 
mington. 

Treasurer: Mrs. C. E. Judd, Raleigh. 



AN APPEAL TO THE DOCTORS FROM 
THE AUXILIARY 

Please take Hi/geia through the Auxiliary. 

The reason is: The Au.xiliary maintains 
a bed at the Sanatorium where doctors and 
their children, nurses, and other tubercular 
patient without the necessary funds, are 
nursed back to health and u.sefulness. 

The Auxiliary is trying to raise an endow- 
ment fund of $10,000 to meet the expenses 
of this bed. For a limited time the Auxiliary 
gets $L25 for every $2.50 subscription to 
Hygeia. 

Please help this worthy cause by sending 
your check and address for the subscription 
to this magazine to Mrs. K. B. Pace, State 
Hygeia Chairman, Greenville, N. C. 

Thank you ! 

Anna L. Strosnider. 



MINUTES OF THE SEMI-ANNUAL 
MEETING OF THE BOARD OF DIREC- 
TORS OF THE AUXILIARY TO THE 
MEDICAL SOCIETY OF THE STATE OF 
NORTH CAROLINA, THURSDAY, 
OCTOBER 12, 1939 

The Board of Directors of the Auxiliary 
to the Medical Society of the State of North 
Carolina met at Sanatorium, North Carolina, 
Thursday, October 12, 1939, at noon. Before 
the business session, the board memljers 
were guests of Mrs. P. P. McCain, at a most 
enjoyable luncheon. The session was called 
to order by Mrs. C. F. Strosnider, president 
of the auxiliary. Mrs. Isaac Manning led the 
members in the Lord's Prayer as an invo- 
cation. 

In her introductory remarks, Mrs. Stros- 
nider referred to the fact that she had not 
been formally installed as president (a 
severe case of mal de mer rendering her 
incapable of receiving the gavel from Mrs. 
Elliott at the annual meeting aboard ship). 



In spite of this handicap, she assured the 
Board that she would take great pride in 
doing her best to carry out the objectives 
and ideals of our organization. Mrs. Stros- 
nider also paid tribute to the efficiency of 
Mrs. Elliott as past president, and thanked 
her for her help in the organization of this 
year's work. The president welcomed the 
Board members, expressing her reliance 
upon them in building an "Auxiliary house 
with a firm foundation that gives security, 
refuge, and strength." 

Mrs. P. P. McCain bade the members wel- 
come in her own gracious manner. 

The roll call showed eighteen members 
present. At this time the president recog- 
nized Mrs. J. B. Cramner, Wilmington, N. 
C, welcoming her, and calling attention to 
her speech "State Medical Auxiliary" in the 
1935 Medical Transactions. Mrs. Strosnider 
urged all members to read this speech. 

Mrs. Strosnider announced that she had 
received several letters from members of the 
board expressing their regret at not being 
able to attend the meeting. It was moved 
by Mrs. P. P. McCain, seconded by Mrs. R. 
S. McGeachy, that the secretary write notes 
of sympathy to Mrs. C. R. Hedrick on the 
death of her brother, and to Mrs. K. B. Pace 
and Mrs. J. C. Tayloe on their illnesses. 
There were notes of regret at their absence 
from our Advisory Board. 

Mrs. P. P. McCain, Chairman of Past 
Presidents, reported that they were "all in 
good condition". She invited us to visit Mr. 
L. S. Sawyer who now occupies the McCain 
bed at the Sanatorium. 

The president called attention to two cor- 
rections to be made on our stationery. Dr. 
S. D. Craig is chairman of the Advisory 
Board, and Mrs. K. B. Pace has been ap- 
pointed Hygeia Chairman in the place of 
Mrs. W. e". Overcash. 

Mrs. Strosnider a.sked every one at this 
time to secure a copy of the by-laws, and a 
copy of each of the written reports of the 
various chairmen. These reports entailed a 
great amount of work and typing, and the 
chairmen were thanked for their successful 
efforts. The board members were asked to 
clip these reports in their note books and to 
read them carefully. The purpose of these 
written reports is that they shall be infor- 
mation sheets, to give in convenient form 
the past, present, and future of the otticcs 
and committees. Mrs. P. P, McCain was 



February, lfl40 



WOMAN'S AUXILIARY 



121 



asked by the president to edit these sheets. 
The president presented a questionnaire to 
be used as an examination for auxiliary 
members. Mrs. Isaac Manning moved and 
Mrs. R. S. McGeachy seconded that Mrs. P. 
P. McCain prepare a li.st of answers for the 
questionnaire — these answers to be pub- 
lished together with the minutes. 

Mrs. Strosnider urged that we u.se our 
local newspapers in getting the ideals and 
ob.iectives of our organization before the 
public. She suggested that we give them a 
sheet of our official stationery, on which we 
write: (1) the auxiliary dues and how they 
are spent, (2) a list of philanthropies and 
outstanding things in which we participate, 

(3) the historical facts of the McCain Bed, 

(4) the date of auxiliary meetings. 
Speaking of the plan for the year's work, 

Mrs. Strosnider announced that our motto 
would be "Be Informed and Inform Others" 
as to ob.iectives of auxiliary, history of aux- 
iliary, recent health laws, socialized medi- 
cine, etc., and from our Advisory Board 
•learn how to disseminate knowledge about 
ithem. The councillors were urged to do per- 
sonal work, to see every eligible doctor's wife 
in the district and invite her to join the aux- 
iliary, to enlarge the membership, and to set 
a new record by collecting dues early. Each 
officer was asked to know and perform her 
duty well. 

Mrs. Joseph Elliott, first vice president in 
charge of councillors, urged all councillors 
to follow out persistently the outlined pro- 
Igram of activity. 

j Mrs. Alfred Kent, second vice president, 
'chairman of McCain Bed, spoke briefly on 
her written report. 

j The treasurer, Mrs. E. C. Judd, presented 
jthe following report: balance in General Ex- 
pense Fund $180.88; balance in upkeep of 
;McCain Bed Fund $296.98; amount in Mc- 
jCain Endowment Fund $1,426.66; amount 
iin Student Loan Fund $619.79. Mrs. Judd 
moved the adoption of this report. Mrs. 
iJoseph Elliott seconded the motion, and the 
ffeport was unanimously accepted. Upon the 
motion of Mrs. Frederick 'Taylor and the 
second of Mrs. Joseph Elliott, Mrs. Judd was 
iriven a rising vote of thanks for her efficient 
service. 

Next in order were the reports of the 
committee chairmen, all of whom referred 
briefly to the aforementioned written re- 
ports, which each board member had secured. 



Mrs. Isaac Manning moved, and Mrs. R. S. 
McGeachy seconded that the report of Mrs. 
Frederick Taylor, program chairman, be ac- 
cepted and that she proceed with her activi- 
ties. The motion was carried. The president 
showed the written ballot votes whereby she 
was authorized to appoint a legislative chair- 
man and chairman of Jane Todd Crawford 
Memorial, which is a project of the Southern 
Medical Auxiliary. Mrs. Hamilton McKay 
of Charlotte was chosen Legislative Chair- 
man and Mrs. Thomas Leslie of Kinston, 
Jane Todd Crawford Memorial Chairman. 

The work of Mrs. Erick Bell, as historian, 
was emphasized. It shall be her duty to keep 
a complete and detailed history of the or- 
ganization. Several councillors gave inter- 
esting and informative reports of the work 
done in their districts. 

As new business, the president appointed 
Mrs. Ben Lawrence chairman of the nomi- 
nating committee to name officers for the 
coming year. Other members, nominated 
from the floor, were as follows: Mrs. W. P. 
Knight (nominated by Mrs. F. R. Taylor, 
seconded by Mrs. Joseph Elliott) ; Mrs. J. 
R. Terry; Mrs. J. B. Sidbury; Mrs. W. H. 
Smith. 

The president appointed Mrs. James W. 
Vernon as official representative to Southern 
Medical Association Meeting. 

The president brought up the question of 
the auxiliary supporting a bed in Western 
Sanatorium. After some discussion, Mrs. 
Ben Lawrence made the motion, which was 
seconded by Mrs. J. W. Vernon, that we do 
support such a bed. The motion was car- 
ried. As a committee to investigate and pro- 
pose plans for such work, the president ap- 
pointed Mrs. P. P. McCain, Sanatorium; 
Mrs. Julian Moore, Asheville; Mrs. S. M. 
Bittinger, Black Mountain; and Mrs. M. L. 
Stevens, Asheville. 

Mrs. Strosnider off'ered a prize of $5.00 
to the district which has the largest percent- 
age of paid up members by May 1, 1940. 

Mrs. E. C. Judd read a tentative budget 
for the year and moved its adoption. Mrs. 
Lawrence seconded the motion. The budget 
was accepted. 

Mrs. Strosnider announced that the State 
Medical Meeting will be held May 13, 14, and 
15 at Pinehurst. She appointed as a pro- 
gram committee for the Auxiliary, Mrs. C. 
L. Gray, Sanatorium; Mrs. Earl Overcash, 



122 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



Southern Pines; and Mrs. R. A. Matheson, 
Jr., Raeford. 

The president announced that the spring 
board meeting would be held sometime in 
March at her home. She graciously invited 
those members who live at a distance to be 
her over-night guests. 

Mrs. Ben Lawrence stood to thank Mrs. 
P. P. McCain on behalf of the Board for her 
delightful hospitality, which we all enjoyed 
to the utmost. 

Respectfully submitted, 

LiDiE Penton Freeman 
(Mrs. J. D. Freeman) 
Recording Secretary. 

Members Present 



Mr.s. 


C. 


F. 


Slrosnider 


Mrs. 


W. E. Overcash 


Mrs. 


P. 


P. 


McCain 


Mrs. 


G. E. Bell 


Mrs. 


.1. 


A. 


KUintt 


Mrs. 


C. D. Thomas 


Mrs. 


A 


A 


Kent, Jr. 


Mrs. 


H. W. McKay 


Mrs. 


E. 


C. 


Judd 


Mrs. 


T. S. See 


Mr.«. 


J. 


D. 


Freeman 


Mrs. 


W. T. Rainev 


Mrs. 


F. 


R. 


Taylor 


Mrs. 


Ben Lawrence 


Mrs. 


R. 


S. 


McGeachy 


Mrs. 


W. P. Knight 


Mrs. 


I. 


H. 


Manning- 


Mrs. 


J. W. Vernon 



3n ilptttnnam 



DR. W. H. COWELL 

Dr. W. H. Cowell. of Shawboro, died December 
lis, 1938, and was laid to rest in the family cemetery 
at Shawboro. 

Dr. Cowell practiced medicine in Currituck County 
from his youth. He was the son of Dr. W. H. 
Cowell, Sr. and Mrs. Martha DeFord Cowell. He 
was educated at Roanoke College in Salem, Vir- 
ginia and at the Universities of Kentucky and 
Pennsylvania. In college he stood high in fraternal 
circles. 

Dr. W. H. Cowell, Sr., practiced medicine in Cur- 
rituck County for several years. He represented 
his county in the General Assembly several terms, 
and was also treasurer of Currituck County for 
several years. Dr. T'owell followed somewhat in the 
footsteps of hi.s' father, taking great interest in the 
affairs of his county and state. He was a member 
of Governor Locke Craig's staff from 1912 to 191fi, 
and a member of the Board of Directors of the 
.State Hospital in Raleigh. He took great interest 
in highway work and was at one time chairman of 
the Currituck Highway Commission. 

His cbuj'ch proclivities were with the Baptists. 
He was a Master Mason. Dr. Cowell's advice was 
sought a.s* a financier in state and county affairs. 

Dr. Cowell will be missed throughout the county 
by all classes; hut next to his sister. Miss Sudio 
Cowell, and his brntlier, Virginius Cowell, those who 
will miss him most are thos'c who depenrled on him 
in sickness and distress. He placed suffering 
humanity nn the same plane and visited alike the 
palaces of the rich and the hovels of the poor, 
ministering at all times to their necessities. 

He was a Democrat in politics, but was tolerant 
of the views of others. 

Dr. Cowell never married. He had a most sympa- 
thetic and gentle demeanor in the sick room. He 



had a retiring nature and always frank and honest 
with no semblance of pretense. His daily work ex- 
pressed the high ideals of our profession. 

He was a member of the Seaboard Medical Asso- 
ciation, the District Medical Society and others. 

He lived a useful life and in deed fulfilled the 
sentiment expressed by the poet: 

" 'Tis a thought divine the wisest thought of sages 
He who lives to bless his age and time has lived 
for all the ages." 

Dr. W. T. Griggs. 

A friend and co-worker. 



DR. JAMES DaCOSTA HIGHSMITH 

We, the members of the Cumbeiland County Medi- 
cal Society, W'ish to. expj'ess the sorrow we feel in 
the death of Dr. James DaCosta Highsmith, one of 
our honored and beloved members who served with 
distinction in the office of president, the highest 
honor we could confer upon him. His example, 
bis influence, and his ideals were of a high order. 
His upright life and his high-toned Christian charac- 
ter will continue to exert a beneficent influence 
among us. 

He was not only a well -beloved and successful 
physician, but also a public-spirited and influential 
citizen, interested in all the progressive movements 
that tended toward the development of the com- 
munity and the upbuilding of the character of its 
citizens. Envies and strife found no harbor in his 
soul, and in all the contacts of his life he mani- 
fested to the highest degree that greatest of all 
virtues, charity. 

We wish to express to the members of his family 
our deep sympathy in the loss they have sustained, 
and to assure them that his memory will ever be 
cherished by the members of this society. We re- 
ioice with them in the asssurance that this separa- 
tion is only temporary, for, through faith, we look 
forward to abundant entrance with him into a life 
of everlasting joy and peace. 

We wish to have these resolutions spread on a 
special page in the minutes of this society, a cony 
sent to his family, and a cony published in the 
North Carolina Medical Journal. 

Cumberland County Medical Society, 
(Signed) O. L. McFadyen, M.D., Secretary. 



CHARLES STAPLES MANGUM 

Charles Staples Mangum was born in Greensboro 
on July 14, 1870. His fathev was Adolphus W 
Mangum, a member of the Faculty of the University 
of North Carolina from 1875 to 1890. His mother 
was Laura Overman, of Salisbury. N. C. 

He graduated from the University of North Car- 
olina with an A.B. degree in 1891. Ho was Physical 
Director at the University of Noith Carolina from 

1890 to 1892. and a member of the faculty during 

1891 and 1892. He was an end on the football team 
in 1891, and winner of a prize for the best all-round 
athlete in college in 1890. He was* one of the origi- 
nal members of the Lfniversity Glee Club and com- 
))0sed one of the verses of "Hark the Sound." 

Dr. Mangum left the University of North Carolina 
in 1892 and went to Jefferson Medical College. He 
graduated there in medicine \\\ 1894. and was win- 
ner of the Therapeulic prize at graduation. He was 
Assistant Demonstrator of Anatomy at Jefferson 
Medical School during 1894-9.";. and in 189.5-96 was 
Assistant Surgeon at the Lehigh and Wilkesba]-re 
Coal Company. He won the Anpleton Prize for the 
best examination before the North Carolina Board 
of Medical Examiners in 1896. He did graduate 
work at the University of Chicago and Harvard 



it 



February, 1940 



BOOK REVIEWS 



123 



Medical School. He went back to the University of 
North Carolina in 1896 and was Professor of Physi- 
ology and Materia Medica there from 1896 to 1900. 
From 1900 to 1905 he was Professor of Pharma- 
cology and Demonstrator of Anatomy. In 1905 he 
became Professor of Anatomy and held that position 
until his" death. 

It would be superfluous to tell any group of medi- 
cal men in North Carolina what a great teacher of 
anatomy Dr. Mangum was. It suffices to say that 
his students, as advanced standing students in other 
institutions, always' showed more knowledge of 
anatomy than the regular students of those insti- 
tutions. 

In 1933 there came to him a great honor: both 
unsought and, we think, unwished for. That was 
the office of Dean of the Medical School. He was 
Dean of the University of North Carolina Medical 
School from 1933 to 1937. During his Deanship, 
largely due to his efforts', a relationship was estab- 
lished between the State Board of Health and the 
Medical School, which in turn led to the creation 
of the Division of Public Health of the Medical 
School. This undoubtedly marked another great 
milestone in the development of the University of 
North Carolina Medical School. It was during his 
administration that the plans for the medical build- 
ing which is just now being completed really began 
to take concrete form. 

Dr. Mangum was a member of the University 
Medical School Faculty for forty-three years. He 
was' a member of the Zeta Psi Fraternity, of The 
Order of Gimghoul, and of several other organiza- 
tions. 

Dr. Mangum was married in 1900 to Miss Laura 
Rollins Payne of Washington, D. C. He is survived 
by Mrs. Mangum and one son, Charles Staples Man- 
gum, Jr. 

We have sketched I'ather bi'iefly some of the great 
accomplis'hments that Dr. Mangum has performed 
in the field of education and science. It is perfectly 
proper after having outlined these things, that we 
speak of Dr. Mangum in a more personal way, be- 
cause many of us were his students. During the 
forty-three years he taught at the University of 
North Carolina, hundreds of students passed through 
his classes. He was known familiarly to the medi- 
cal students as "Dr. Charlie." We don't believe that 
there is a student of his alive today who would not 
know whom you were talking about if you mentioned 
"Dr. Charlie." However, the student's familiarity 
with Dr. Mangum existed only in his heart, because 
Dr. Mangum in his classroom showed a dignity that 
demanded the respect of every student in his class. 

Dr. Mangum was the soul of wit. His quips will 
be heard down through the years, wherever there 
is a medical .student of his to recount them. He 
was the essence of gentleness and courtesy. A more 
understanding heart than his never beat. We all 
loved and still love him. His polish was not veneer. 
It never broke or wore off. He was a composite of 
the best types of the "Southern gentleman" which 
hundreds of authors have described. 

We give you Charles Staples Mangum: A gentle- 
man, a scholar, a teacher, and our friend. 

(Signed) Dr. S. D. McPher.son 
Dr. T. C. Kei-ns 
Dr. W. R. Stanford. 

DR. MARTIN L. STEVENS 

Dr. Martin L. Stevens, of Asheville, died suddenly 
at his home, 155 Montford Avenue, on Saturday 
morning, January 20. Dr. Stevens, the senior mem- 
ber of the Buncombe County Medical Society, was 
a native of Thornville, Ohio. After graduating from 
the Baltimore Medical College in 1891 and serving 



a year as resident physician of the Maryland Gen- 
eral Hospital, he came to Asheville in 1899 as resi- 
dent physician at Winyah Sanatorium, and later 
became physician-in-charge. After leaving this post. 
Dr. Stevens went to New York for post-graduate 
study, and entered private practice in the treatment 
of tuberculosis' upon his return. He was a former 
member of the State Board of Medical Examiners, 
and in 1930 was president of the Medical Society of 
the State of North Carolina. From 1924 almost con- 
tinuously until his death, he represented the state 
society in the House of Delegates of the American 
Medical Association. He was a charter member of 
the National Tuberculosis Association, and the first 
president of the State Tuberculosis Association. 

Dr. Stevens was a Fellow of the A. M. A., a 
Fellow of the American College of Physicians, a 
member of the American Climatalogical Association 
and of the Southern Medical Association. He was a 
certified specialist of the American Board of In- 
ternal Medicine. He was married in 1894 to Miss 
Mary Lulu Patterson, who sui-vives him. Of him 
one of his friends has written: "I hope that when 
I reach his age, I can be as well loved as he was. 
He was one grand man, a good physician, a calm- 
ing influence when the waters became stoi-my, and 
a Christian gentleman of the highest rank." 



AN INTRODUCTION TO GASTRO-ENTEROLO- 

GY. By Walter C. Alvarez, M.D. Price, $10.00. 
778 pages. New York: Paul B. Hoeber, Inc., 1940. 

This', the third edition of the work originally called 
THE MECHANICS OF THE DIGESTIVE 
TRACT, has been thoroughly revised and brought 
up to date. It is now nearly twice the size of the 
first edition, and covers the entii'e field of gastro- 
enterology as fully as a single volume could. In 
the front of the book is a quotation from Pavloff: 
"I am convinced that it is by frequent interchange 
between the physiologist and the physician that the 
common goal of phys'iological science and of medi- 
cal art will be mo.st quickly and safely reached." 
Dr. Alvarez is perhaps the most successful com- 
bination of physiologist and physician living; and 
he also possesses the rare gift of knowing how to 
WTite what he knows in such simple and charming 
words that is a real pleasure to read after him. 
One feature of the book that will appeal to the 
busy reader is that each chapter except the last one 
has a comprehensive s'ummary at the end. The final 
chapter, "On Books and Reading", does not lend 
itself to such treatment, and deserves careful read- 
ing in its entirety. 

Besides its clear style, the contents of the book 
are enriched 186 illustrations, and a bibliography of 
more than 100 pages is added for those who care 
to follow any particular line of investigation. The 
type, the illustrations, and the binding of the book, 
all are a tribute to the ait of the printer. 

ENDOCRINE GYNECOLOGY. By E. C. Ham- 
blen, B.g., M.D., F.A.C.S. Price $5.50. Pp. 453. 
Charles C. Thomas Co. 

It has become increasingly difficult for the non- 
specialized readei' to keep abreast of the advancing 
facts and the changing nomenclature of gynecologic 
endocrinology. It is well, then, that from time to 
time monographs on this subject should be issued 
both for the sake of the specialist and as a reference 
work for workers in other fields. 

Hamblen's book is a clear and adequate presenta- 
tion of this somewhat complex subject, proceeding 
in a logical way from physiology to pathologic 



124 



NORTH CAROLINA MEDICAL JOURNAL 



February, 1940 



alterationb' of endocrine functions. The chapters on 
sex-endocrine syndromes and growth abnormalities 
are especially useful, being well inllustrated. Mens- 
trual disorders, frequently so baffling to the less 
experienced in this field, receive extended considera- 
tion, which should prove helpful to every reader. 
The book has benefited by the excellent typographi- 
cal treatment which we have learned to associate 
with the firm of Charles C. Thomas. 

CLINICAL ALLERGY, ASTHMA AND HAY 
FEVER. By Francis M. Rackman, M.D. Price 
.$7.50. Pp. tin. New York: The Macmillan Com- 
pany, 1931. 

In this book the field of allergy is covered so 
completely by a physician of such wide and thorough 
experience that one wonder.s why so many bibli- 
ographies are given. The book is divided into two 
parts'. The first deals with hypersensitiveness; 
anaphylaxis in animals and man, why and how pro- 
duced; the chemistry of hypersensitiveness; anaphy- 
laxis and desensitization; the nature and origin of 
allergy. The author goes back to Greece for the 
beginning of the study of allergy and follows the 
history and methods of treatment up to the present. 
In this part the necessity for proper history taking 
and jjhysical examinations is set forth. 

The second part deals chiefly with the clinical 
manifestations of the different types of allergy, and 
goe.s' thoroughly into the use and reactions of serums. 
The pathology of asthma is fully dealt with and 
illustrated. It is shown that many of the vague 
sufferings of people in the past have been due to 
allergic conditions; that advancement in allergy is 
adding more diseases to its field; that an allergist 
is not a man so far removed from the medical 
world as was once thought, but that allergy can be 
more thoroughly understood by each physician in 
practice. This book will be of great help to the 
medical man and to the student of allergy. 

PHYSIOLOGICAL CHEMISTRY. By Albert P. 
Mathews. Ph.D., Andrew Carnegie Profes.-or of Bio- 
chemistiy, The University of Cincinnati. Sixth Edi- 
tion. Illustrated. Price $8.00. Baltimore: The Wil- 
liams & Wilkins Company, 1939. 

The sixth edition of Mathews' PHYSIOLOGICAL 
CHEMISTRY has been thoroughly revised and 
brought up to date. Many new references have 
been added to older references which illustrate the 
historical background of the science. The practical 
section has been omitted and is published .separately 
by the same publisher. To the reviewer this seems 
a considerable loss. The book is comprehensive and 
authoritative. The material has been selected to be 
of particular use to medical students, practitioner's, 
and graduate students. This book needs no intro- 
duction to the medical profession, as it has been a 
standard work for twenty-four years. 

MODERN MEDICINE IN THE UNITED 
STATES is a 40-page pamphlet by Dr. S. Adolphus 
Knopf of New York, printed by patients at the 
Potts Memorial Hospital for Rehabilitation. In it 
Dr. Knopf gives a comprehensive survey of present- 
day medical economic problems: compulsory sick- 
ness insurance, group practice, irregular practi- 
tioners, patent medicines, self -medication, criticism 
of organized medicine, venereal disease, the Wagner 
Bill and the National Health Program. After this 
survey, Dr. Knopf gives constructive suggestions 
for economy and efficiency. The author is entirely 
in sympathy with the family doctor, yet is mindful 
of the people's need for medical service. Its sanity 
makes it a valuable contribution to the study of a 
perplexing problem. 



Powers & Anderson 




iini NKW urn. DIM. 
2 SOUTH r>TH STREET 

RICHMOND, VA. 

Hiadiiuarters for Surgical, Hosiiital, 
(nid Dented Supplies 

The Oldest and Largest Surgical and Hospital 
Supply Firm in the South 



Powers 6c Anderson Surgical 
Instrument Company 




111 It M-.U' MiltKOI.K STORE 
227 W. YORK STREET 

NORFOLK, VA. 

SURGICAL INSTRUMENTS, 

HOSPITAL SUPPLIES. Etc. 



March, 1940 



ADVERTISEMENTS 



III 



STUDIES /I /// A VITAMUOSES 




This page is the third of a series on vitamin deficiencies presented 
by the research division of The Upjohn Company because of the 
profession's widespread interest in the subject. A full color, tvro- 
page insert on the same subject appears in the March 9 issue of 
The Journal of the American Medical Association. 



Jtnhibition of grovyrth in the 
rat produced by restriction of 
vitamin A in the diet. The ani- 
mals, litter mates, vrere 21 days 
old at the start of the experiment 
which was continued for 33 days. 
The animal at right received a 
diet containing all nutritive 
substances except vitamin A; 
the animal at left, an adequate 
diet. Note the xerophthalmia in 
vitamin A deprived rat. 




Retardation of Growth Due to 

Vitamin A Deficiency 




The upper graph records the 
growth ol a rat on a complete 
diet. The lower graph records 
the growth of a Utter mate on a 
vitamin A deficient diet; it de- 
picts almost immediate retarda> 
lion and cessation ci growth. 



While vitamin A is no more essential for growth than are 
other indispensable nutritional factors, its deprivation leads 
to well-defined growth retardation in man as well as in 
experimental animals. This action 
is so predictable that it is em- 
ployed as a basis for one of the 
methods of vitamin A assay. The 
immediate effect of vitamin A 
deficiency on growth is cessation 
of endochondral bone formation. 
The curves reproduced illustrate 
the prompt growth-inhibiting 
effect of vitamin A 
deprivation in rats. 



lUPJOHNl 



IV 



CONTENTS 



March, 1940 



North Carolina Medical Journal 

Official Organ of 
The Medical Society of the State of North Carolina 



VOLCSffi 1 
NCMB£B S 



March, 1940 



1 1.00 .4 VEAK 

30 CENTS A COPY 



contents 



Original Articles 

Medical Research: The Story of Sulfanilamide 
_E. K. Marshall, Jr., M. D. 125 

Ureent Surgery Upon Infants Under One Year 
of Age— F. Webb Griffith, M. D. - - - - 129 

The Prevention and Treatment of Pehic Floor 
Injuries— B. P. Watson, M. D. - - - - - 134 

A Tuberculosis Case-Finding Program in a 
Woman's College— Ruth M. ColUngs, M. D. 138 

Chronic Acetanilid Poisoning with Addiction — 
Donald Mcintosh, Jr., M. D. - - - - - 143 

The Management of Old Contractures of the 
Hand Resulting from Third Degree Burns 
—Randolph Jones, Jr., M. D. - - - - - 148 

Diagnosis and Treatment of Neurosyphilis— 
J. P. Da\nf. M. D. lo2 

A Preliminary Report of an Analj-sis of the 
Deaths Among Individuals With Syphilis in 
North Carolina During 1938— G. M. Leiby, 
M. D. 15* 

Artificial Rupturing of the Membranes as a 
Method of Induction of Labor — John C. Tay- 
loe, M. D. 159 

Editorials 

The Preparation of Manuscripts 161 

North Carolina's Vital Statistics for 1939 - - 162 

Sulfapyridine vs. Serum in Lobar Pneumonia 162 

The "Common Cold" - - - 163 

Case Reports 

Duke Hospital Clinico-Pathological Conference 164 
Clinico-Pathological Conference. City Memorial 
Hospital 167 



The Bulleiin Board 

State Board of Health - - 169 

New Building for State Laboratory of Hygiene 169 

News Notes from Duke University School of 

Medicine and Duke Hospital ----- 169 

News Notes from the School of Medicine of 

the University of North Carolina - - - - 170 

News Notes from the Wake Forest Medical 

School 170 

North Carolina Mental Hygiene Society - - 170 

Tri-State Medical Association 170 

American College of Physicians 171 

American Board of Internal Medicine - - - 171 

Convention for the Revi.^ion of the Pharmaco- 
poeia of the United States of America - - 171 
Education Qualifications of Health Officers - 171 

County Societies ----- 171 

News Notes -- 1^1 



Woman's AuxILL^RY 



172 



Beginning of the Woman's Auxiliary - 

An Examination for Members of the Auxiliary 

to the Medical Society of the State of North 

Carolina 173 

Notices ------------- 175 



In Me.mori.\m 

175 

Book Reviews 

176 



Entered as 5econc!-c!a.*< matter Janaan' J. l'*". at the PMloffice at Winston-Salem. North Carolina, under the .\ct of .\uotO 
S4. 1912. Copyripht ISM hy the Medical Society of the State of North Carolina. 



North Carolina Medical Journal 

Owned and Published By 
The Medical Society of the State of North Carolina 



Vol. 1 



March, 1940 



No. 3 



MEDICAL RESEARCH : THE STORY OF SULFANILAMIDE 

E. K. Marshall, Jr., M.D. 

Professor of Pharmacology and Experi- 
mental Therapeutics 
The Johns Hopkins University 

Baltimore 



A School of Medicine has primarily two 
objectives : the training of future physicians 
and the advancement of knowledge by medi- 
cal research. For the attainment of the fir.st, 
the .second, properly pursued, is neces.sary ; 
and the two, wi.sely combined, may produce 
what the distinguished Dean of this School 
of Medicine recently described as "the 
biologically minded physician". Organized 
medical research, at least in the so-called 
pre-clinical subjects, is a recent innovation. 
With the partial exception of the anatomical 
laboratory, laboratories in medical .schools 
for the training of students and for research 
are largely creations of the last three- 
quarters of a century. E.xcept in two or 
three instances, all of the physiological lab- 
oratories worthy of the name have been 
established since the middle of the past cen- 
tury ; the first pathological laboratory was 
founded by Virchow in Berlin in 1856 ; 
physiological chemistry as a separate dis- 
cipline split off from physiology quite late, 
and Hoppe-Seyler headed the first indepen- 
dent laboratory devoted to this subject at 
Strassburg in 1872; pharmacology as the ex- 
perimental science we now know began when 
Buchheim established its first laboratory in 
his private house at Dorpat in 1849. Coin- 
cident with the growth of organized labora- 
tories for medical research, the whole face 
of medicine has changed, and it is probably 
no exaggeration to say that a greater ad- 
vance has been made in the art and science 
of medicine in this 75-year period of labora- 
tories than in all previous medical history 
put together. 



Address delivered at the dedication of tlie new Medic.il and 
Public Health buitdin? of the University of North Carolina. 
Sesqui-Centennial Celebration, December 4, 1939. 



Many of you who are not students of the 
medical .sciences are but little interested in 
medical research and theories of disease. 
When illness overtakes you, you wi.sh to be 
cured "safely, quickly and pleasantly". I 
doubt if physicians can carry out this ideal 
treatment at present, but the lot of the di- 
seased person today is so immeasurably im- 
proved over what it was a hundred years 
ago that another century may indeed see 
doctors curing their patients "safely, quick- 
ly and pleasantly". This improvement has 
all come about as a result of the labors of 
thousands of unknown workers at medical 
research — some in remote and isolated places 
— during the past century. 

A decade ago, the British Government had 
occasion to find a formula for delimiting the 
field of medicine, and adopted the following : 

"Medical research deals by no means only 
with the cure of disease. It deals with the 
proper development and right use of the 
human body in all conditions of activity and 
environment, as well as with its protection 
from disease and accident, and its repair." 
This marks out a vast territory wherein lies 
the whole business of human life on this 
earth, in all its ramifications from the cradle 
to the grave. Before the medical research 
student stands, directly or indirectly, the 
challenge of the prevention, alleviation and 
cure of human diseases. The lessons of 
science show clearly, however, that the in- 
vestigator having a definite practical goal in 
view frequently defeats his own ends by his 
impatience of any but the paths that seem 
direct and obvious. The cure of disease can 
only be effective in so far as knowledge 
guides it, and important discoveries come 



126 



NORTH CAROLIXA MEDICAL JOURXAl 



March, 1940 



generall\' from the work of those who seek 
knowledge for its own sake. The man into 
whose lap the ripe fruit of discovery falls, 
when the time is propitious, has builded on 
and profited from countless pieces of re- 
search and the long labors of a host of other 
investigators. 

This point of the pursuit of medical re- 
search for its own sake, of allowing the in- 
vestigator to attempt to answer questions in 
a desire only to satisfy his own curiosity, 
seems to me to be important in this day and 
age of practical things. Last year at the 
opening of The Squibb Institute for ^Medical 
Research, ilr. Abraham Fle.xner gave an ad- 
dress on "The Usefulness of Useless Knowl- 
edge" in which he stressed this point. !May 
I quote two sentences : 

"The men and women who are today mak- 
ing the largest contribution to human happi- 
ness and human health are the quiet workers 
in laboratories and libraries and who in the 
pursuit of a devoted career do not pause to 
ask themselves 'What is the use?'." 

"Throughout the whole history of science 
most of the really great discoveries which 
had ultimately proved to be beneficial to 
mankind had been made by men and women 
who were driven, not by the desire to be 
useful, but merely by the desire to satisfy 
their curiosity." The waste in such a pro- 
gram seems enormous, but it is not really so. 
No one can tell when knowledge acquired by 
an investigator satisfying his intellectual 
curiosity in a field of medical research ap- 
parently quite remote from practical things 
may be vital to the health of mankind. No 
matter how remote and isolated, real re- 
search is the life blood of a living medical 
school. 

Permit me to pass now from these general 
remarks and tell a story of recent medical 
research which will, I hope, emphasize the 
importance of such research and illustrate 
some of the above points. You all know from 
your reading of newspapers and magazines 
that in the past three years, a new drug — 
sulfanilamide — has been used for the treat- 
ment of serious bacterial infections. I won- 
der, however, if all of you realize that the 
introduction and use of this drug marks, in 
the opinion of many observers, a period real- 
ly "epochal in the history of medicine". Per- 
sonally, I should consider its introduction 
into medicine as an event to be ranked with 
the two really great thei'apeutic discoveries 



of all medicine — the discovery of anesthesia 
and that of antiseptic (or aseptic) surgery. 

Let me try to relate briefly the story of 
sulfanilamide ; it is absorbing. We must 
start way back in the year 1904, when Ehr- 
lich and Shiga first showed that a fatal ex- 
perimental infection of mice caused by a 
protozoan — a trypanosome — could be com- 
pletely cured by a single injection of a rela- 
tively harmless red dye. Regardless of the 
fact that other species of infected animals 
did not respond like mice and that these ex- 
periments were of no immediate practical 
value, a real advance had been made in prov- 
ing for the first time that a hitherto invaria- 
bly fatal infection could be cured by a chemi- 
cal agent. As you all know, six years later 
Ehrlich announced the discovery of the 
organic arsenical — Salvarsan — as a cure for 
syphilis. However, despite the advances 
which have been made by medical research- 
ers since Ehrlich's time in the chemotherapy 
of protozoan infections, nothing of any 
practical importance was developed in the 
chemotherapy of bacterial infections until 
within the last three or four years, when 
drugs containing the sulfonamide group 
were introduced. This failure was not due 
to the lack of research along the.se lines, but 
probably to the fact that such investigation 
is still in the stage of haphazard trial and 
error. As far back, however, as 1911, ilor- 
genroth and Levy had found that a chemical 
substance related to quinine — ethylhydrocu- 
prein — would cure pneumococcus septicemia 
in mice ; the only instance until a few years 
ago of the cure of an experimental bacterial 
infection b.v a drug. The curative dose was 
very near the lethal one, however, and this 
remedy when tried in pneumonia in man 
was found too toxic to be given in sufficient 
dosage for effective therapy. 

Three years before Morgenroth and Levj-'s 
work, in 1908, the chemical compound sul- 
fanilamide was prepared by a chemist, Gelmo, 
working at the Royal Technical Hochschule 
of Vienna, apparently with the sole desire 
to satisfy his curiosity. A year later chemists 
of the I. G. Farbenindustrie at Elberfeld, 
Germany, prepared azo dyes with sulfona- 
mide and substituted sulfonamide groups 
and found that they were distinguished by 
greater fastness to washing and milling 
than the corresponding sulfonamide -free 
products. As far as is known no attempt 
was made at this time to apply these com- 



March. 1940 



MEDICAL RESEARCH— MARSHALL 



127 



pounds to the control of bacterial infections. 
As the result of a series of investigations in 
the laboratories of the I. G. Farbenindustrie, 
Domagk announced in 1935 that an azo dye 
containing the sulfonamide group prepared 
by Mietsch and Klarer would cure an other- 
wise fatal streptococcus infection in mice. 
Thi.s compound was called Prontosil. Clini- 
cal reports attesting to the efficacy of Pron- 
tosil in patients with streptococcal infections 
appeared shortly before and at the same 
time as Domagk's announcement of his dis- 
covery. Workers at the Pasteur Institute 
late in 1935 suggested that Prontosil was 
liroken down in the body to form sulfanila- 
mide, which was found to be equally as ef- 
fective as Prontosil. This ob.servation was of 
great importance, as it demonstrated that 
a relatively simple organic compound was 
effective as a chemotherapeutic agent in 
streptococcus infections. 

Engli-sh inve.stigators in 1936 confirmed, 
as Long and Bliss did later in America, the 
fact that both Prontosil and sulfanilamide 
would cure an otherwise fatal streptococcus 
infection in mice. In spite of numerous re- 
ports from abroad, dating from 1933, on the 
effect of these drugs in bacterial infections 
in human beings, it was only with the pub- 
lication of a paper in June, 1936, by Cole- 
brook and Kenny of Queen Charlotte Square 
Hospital in London on the remarkable re- 
sults in child-bed fever that much interest 
was awakened in English-speaking countries 
in the new drugs. Investigation of all phases 
of the new drugs has been increasing at an 
accelerating rate since this time. 

Nearly all of the studies with sulfanila- 
mide (and allied drugs) on experimental 
bacterial infections have been made on mice. 
Although supposed at first to be specific 
against hemolytic streptococcus infection, 
sulfanilamide (or allied drugs) has now 
been shown to be curative in experimental 
mouse infections due to meningococcus, 
gonococcus, E. typhi and paratyphi B., Clos- 
tridium Welchii, some strains of dysentery 
bacillus and a staphylococcus. Temporary 
l)rotection only, with delay of death but no 
recovery, was found for mice infected with 
S. aertrycke, Frielander's bacillus, P. pseu- 
dotuberculosis, and P. septica. Against pneu- 
mococcus infections in mice, sulfanilamide is 
much less effective than it is against .strep- 
tococcus infection. In regard to other bac- 
terial infections against which sulfanilamide 



appears to exert a beneficial effect, mention 
must be made of its inhibitory effect on ex- 
perimental tuberculosis in the guinea pig, 
of its remarkable curative effect in certain 
human urinary tract infections, and of the 
suggestive results obtained in the treatment 
of Brucella infections in animals and man. 
Again.st infections caused by protozoa as 
opposed to bacteria, it has been shown that 
this drug is ineffective in rabbit syphilis, 
trypano.some infections in mice, and malarial 
infection in birds. However, it has been 
found to cure acute malarial infections in 
monkeys. Against virus infections, sulfa- 
nilamide and allied drugs have been general- 
ly found to be ineffective, although certain 
favorable results which have been reported 
.iustify further inve.stigations in this field. 

Just what do we mean when we say that 
sulfanilamide cures an otherwise fatal in- 
fection in mice? Let me briefly describe an 
experiment. One hundred mice are given an 
infection of 200-300 lethal doses of a culture 
of streptococci. Fifty are placed on finely 
ground food containing one-half of 1 per 
cent sulfanilamide, while the other group of 
fifty are given the same food without sul- 
fanilamide. In twenty-four hours, many of 
the untreated mice are dead, and the others 
appear very sick; in forty-eight hours all 
the untreated mice have died. The mice 
which have received sulfanilamide look 
healthy and cannot be told from normal un- 
infected mice. After three days, treatment 
is stopped and observation shows that all 
the treated mice survive. If a much smaller 
percentage of sulfanilamide is used in the 
food, a few treated mice may die during the 
three days of treatment, and many will die 
later, only a few surviving. 

That sulfanilamide is a specific cure in 
certain infectious diseases in human beings 
has now been proven by incontrovertible 
evidence. Streptococcus meningitis, an in- 
flammation of certain lining membranes of 
the brain, is almost invariably fatal, giving 
a death rate under all other forms of treat- 
ment of over 97 per cent. Enough cases have 
now been treated with sulfanilamide to show 
conclusively that the death rate can be re- 
duced to something below 35 per cent; with 
prompt recognition of the disease and treat- 
ment the death rate may be made negligible. 
In Fi-ench Nigeria a year or two ago a 
violent epidemic of meningococcus meningi- 
tis occurred. There was not sufficient sul- 



tm 



128 



NORTH CAROUNA MEDICAL JOURNAL 



March, 1940 



fanilamide available for the French physi- 
cians to treat all patients. In those who were 
not treated with sulfanilamide there was a 
mortality- of 74.6 per cent, whereas in sev- 
eral hundred cases treated with sulfanila- 
mide the mortalitj' was only 10.7 per cent. 
This kind of evidence, taken together with 
the numerous other clinical cases of strep- 
tococcus infections in which sulfanilamide 
has been used, shows conclusively that it has 
a great life-sa%ing value. Besides meningi- 
tis, streptococcal infections causing eiysipe- 
las, cellulitis, middle ear disease, pneumonia 
and empyema, septicemia, child-bed fever, 
and osteomyelitis have been found to be 
favorably influenced by sulfanilamide. Sore 
throat, scarlet fever and sinusitis caused by 
streptococcus have been treated, but results 
are less certain than in the above diseases^ 
Infections caused by meningococcus, gono- 
coccus (gonorrhea and gonorrheal arthritis), 
gas bacillus, as well as various urinary tract 
infections, chancroid, trachoma and lympho- 
pathia venereum, appear to respond very 
favorably to treatment with this drug. 
Pneumonia caused by the pneumococcus does 
not respond as do streptococcal infections. 
The effect of the drug is fair in undulant 
fever, and very questionable in typhoid fever 
and staphylococcal infection, while it ap- 
pears certain that the common cold is not 
influenced. 

Sulfanilamide has been found from ex- 
periments on animals to be a relatively non- 
toxic drug. However, large doses cause 
sjTnptoms resembling those seen in poison- 
ing with ethyl alcohol and indicating that 
the central nervous system is mainly affected. 

Although sulfanilamide is a drug possess- 
ing remarkable therapeutic properties, it 
produces at the same time in the human 
subject a wide range of to.xic effects, some 
of which are minor and of no importance, 
while others are severe enough to endanger 
the life of the patient. Of the minor toxic 
reactions may be mentioned those referable 
to the central nervous system — dizziness, 
sometimes severe enough to resemble alco- 
holic intoxication, headache, nausea, indefi- 
nite malaise, cyanosis and acidosis. Symp- 
toms of more importance are fever, skin 
rashes, and occasionally hepatitis, agranu- 
loc\'tosis, and acute hemolytic anemia. It 
should not be used indiscriminately, but only 
in those diseases where sound experimental 



or clinical research has demonstrated its 
value, as its administration may be attended 
with potential danger to the patient. Care- 
ful supervision of a patient taking sulfanila- 
mide should reduce to a minimum the danger 
of its administration. 

The drug is readily absorbed and passes 
into the blood and tissues when given by 
mouth. It is eliminated from the body in 
the urine, partly in unchanged form and 
partly as a conjugated derivative with acetic 
acid formed in the liver (this acetyl deriva- 
tive is inactive therapeutically). The drug 
penetrates all fluids and tissues of the body 
and is present in these, with the exception 
of bone and fat, in about the same amount 
as in blood. This rapid diffusion and pene- 
tration of the drug to all parts of the body 
is undoubtedly one of the factors which 
make it a successful chemotherapeutic agent. 

Numerous drugs allied to sulfanilamide 
have been tried experimentally and clinical- 
ly. None of these appear to be as good or 
better than sulfanilamide, with the exception 
of sulfapyridine. This drug has proven 
about as effective in pneumococcus pneu- 
monia and meningitis as is sulfanilamide in 
hemolytic streptococcus infections. It is also] 
the most eflicient drug known at present for| 
staphylococcal infections. 

What I have said above about the efTecti 
of sulfapyridine in pneumococcal infections 
does not begin to do justice to the miraculous 
effects of the drug. The serum treatment of 
pneumonia which has been in use for many 
years past has proven very effective, but it 
is limited in its use and is extremely expen- 
sive to give. Sulfapyridine has a much wider 
application. Statistical results have been ac- 
cumulated during the past year in sufficient 
numbers to demonstrate its value beyond 
question, but one who has seen pneumonia 
patients treated with this drug does not need 
statistics to be convinced of its value. I can 
recall clearly one of the first cases which 
was treated with the sodium salt of sulfapy- 
ridine. and the dramatic results obtained. 
A woman of sixty-two years was .seriously 
ill with pneumonia and at a stage where 
competent clinicians felt that death was only 
a matter of hours. Two intravenous injec- 
tions of the sodium salt of sulfapyridine 
were given. The next morning the patient's 
temperature was normal and she appeared 
well. This sharp fall of temperature in a 



March, 1940 



MEDICAL RESEARCH— MARSHALL 



129 



patient seriously ill, frequently occurring in 
twenty-four hours after the administration 
of sulfapyridine and accompanied by signs 
that a very sick individual has become a well 
one, is one of the dramatic results of modern 
medicine. Sulfapyridine can be given by 
mouth just like sulfanilamide, and it is only 
in emergencies that intravenous injection of 
the sodium salt is indicated. On the whole 
sulfapyridine appears to be more toxic than 
sulfanilamide. As compared with sulfanila- 
mide it has many disadvantages, but is the 
drug of choice at present for use in pneu- 
mococcus infections, although my own feel- 
ing is that it is by no means the final answer 
to the problem of the chemotherapy of pneu- 
monia. 

No satisfactory explanation of the mode 
of action of sulfanilamide in curing bacterial 
infections has as yet been attained. In a 
consideration of this problem three factors 
are involved: the drug, the infecting organ- 
ism, and the host. The first step in any ex- 
planation is to decide to what extent the re- 
iction between drug and bacteria is sufficient 
and to what extent the defense mechanism 
of the host plays a role in changing the drug 
or in removing the organism. /At present, 
the balance of evidence would seem to indi- 
cate that sulfanilamide affects the invading 
bacteria in the sense of exerting a bacterio- 
static or bactericidal action which is not 
sufficient to effect sterilization without the 
cooperation of the defense mechanism of the 
host. ^ 

This question of the mechanism of action 
of the.se new drugs is a very important one. 
If it could be .solved the search for new drugs 
better than those we already have for treat- 
ing certain infections and also for drugs to 
control infections not susceptible to treat- 
ment would be put on a firm scientific basis, 
independent of the more or less haphazard 
methods used at present. This is where 
medical research in its broadest sense comes 
in. One needs all the information possible 
about the chemical behavior of these drugs, 
about their effect upon the normal and ab- 
bormal human organism, about their effect 
upon different bacteria under various condi- 
tions, as well as information about the re- 
spon.se of different strains or groups of 
bacteria of the same genera and detailed 
information about the intimate metabolic 
habits of various bacteria. Here research, 
no matter how remote and isolated, will be 



needed to fill in and complete the picture and 
enable us to use these new weapons against 
infectious diseases with the full knowledge' 
which should be necessary for their truly 
scientific and intelligent use. 

In conclusion, may I express the hope that 
the use of this fine new building which is 
being dedicated today may stimulate and ex- 
pand the medical research with which the 
name of the Medical School of the University 
of North Carolina has always been associ- 
ated. 



URGENT SURGERY UPON INFANTS 

UNDER ONE YEAR OF AGE 

F. Webb Griffith, M.D. 

ASHEVILLE 

By the term "urgent surgery" I refer to 
those cases which are ordinarily called 
emergency, and also that group demanding 
imperative surgery in which a little more 
time, possibly two or three days, may be 
used for study and preparation. 

Anatomically, an infant is a miniature 
adult, but physiologically and surgically such 
is not the case. He who operates upon one 
of these little ones without taking that fact 
into consideration is subjecting his patient 
to greater unnecessary risk than he who 
operates upon the goiter of a patient with 
acute hyperthyroidism without any more 
preparation or safeguard than is given to 
one with a simple non-toxic goiter. Mature 
judgment, experience in surgical technique, 
and speed without haste are probably more 
essential to success in surgery upon infants 
than in any other field of surgery. 

The occasional operator should not at- 
tempt major surgery upon infants. The ad- 
vice of a pediatrician or an internist especi- 
ally interested in pediatrics is indispensable. 
It has been my custom, whenever possible, 
to place the major responsibility upon the 
pediatrician up to the time the infant comes 
to the operating room and again from the 
moment he leaves the table. During the pre- 
operative and post-operative periods, should 
there be a difference of opinion between the 
pediatrician and the surgeon, the opinion of 
the former should take precedence. 

Among the important pre-operative meas- 
ures to be stressed is restoration of water 
balance by mouth, by hypodermoclysis, or by 
intraperitoneal or intravenous infusions, 



Vent] before the Section on SurseiT. Medical Society of the 
State of Nortli Carolina. Bermuda Meeting, May 13, 1939. 



m 



130 



NORTH CAROLINA MEDICAL JOURNAL 



March, lS4ii 



using plain water, salt and glucose solution, 
or blood as indicated. Rapid dehydration 
and loss of weight from vomiting occur so 
commonly that its correction is pi-obably the 
most important pre-operative indication. 
Where there is no vomiting or other contra- 
indication to food, nursing may be continued 
to within four hours of the operation. 
Morphia is contraindicated before operation, 
but small doses of atropine are usually, but 
not routinely, given. 

Local anesthesia or ether by the open drop 
method have been most satisfactory to me. 
The occasional anesthetist, like the occasion- 
al operator, has no place in the handling of 
these desperately ill infants, unless a trained 
anesthetist is not available. Too frequently 
on the table a patient is allowed to become 
chilled from insufficient covering or from a 
cool operating room, or is loaded down with 
blankets so that there is an enormous loss of 
fluids from perspiration. While this is harm- 
ful to an adult, it may be disastrous to an 
infant. 

Gentleness and precision, desirable in any 
class of surgery, are almost a sine qua non 
in dealing with these frail creatures. Rough 
and ready surgery has no place here. The 
necessity for careful hemostasis and for the 
use of very fine ligatures and sutures is 
obvious. Following operation, the preserva- 
tion of water balance, prevention of acidosis, 
careful maintenance of the body tempera- 
ture, and relief of distention are of such vital 
importance as to demand the closest atten- 
tion of the surgeon or pediatrician, and 
.should not be left to a nurse, regardless of 
her competence. Needless to say, the utmost 
care must be used to prevent infection, and 
should it occur, to detect and treat it in its 
incipiency. Infants react poorly to pyogenic 
infections. One day's absorption from a 
pyogenic infection in an infant may prove 
more harmful than three days' absorption 
of a similar infection in an adult. 

In the brief time allotted me I will simply 
cite a few ca.se histories illustrative of the 
conditions which I wish to discuss. Surgery 
of the ear, nose and throat will not be in- 
cluded, as my experience in those fields has 
been extremely limited. 

Intussusception 

Baby K., age three months, male, was ad- 
mitted with the history that he had been 
vomiting for about thirty hours and had ap- 



parently severe pain in the abdomen. The 
mother stated that the abdomen had been 
greatly swollen for at least twenty-four 
hours, and that the baby had been passing 
blood. Examination showed temperature 
101.5 (rectal), pulse 128, respiration 34. 
Heart and lungs were normal. The abdomen 
was markedly distended, and just to the 
right of the umbilicus a fullness could be 
seen, and a mass the size of a lemon could 
be felt. The mass was hard and appeared 
fixed. On rectal examination it could be felt, 
and when the finger was withdrawn there 
was a .slight blood-tinged discharge. Under 
ether by the open drop method a right rectus 
incision was made. The ileum was found in- 
vaginated into the transverse colon, and was 
very edematous. The first part of the reduc- 
tion was easy, but it was with considerable 
difficulty that the last few inches were re- 
duced. The patient left the hospital in one 
week apparently well. 

Baby F.. age seven months, male, was ad- 
mitted with the history that he had been hav- 
ing abdominal pain for thirty-six hours. The 
mother stated that she had given cathartics, 
but had been unable to get a movement from 
the bowel except blood. Temperature was 
104.4 (rectal), the pulse was so rapid as to 
be recorded with a (?), respiration was 60.. 
The patient appeared actually to be mori- 
bund. The abdomen was so greatly distended 
and rigid that it was impossible to say 
whether or not there was a mass. Our first 
reaction was that it would be useless to 
operate and that to do so would tend to bring 
surgery into disrepute. However, after two 
hours' preparation, during which we partly 
restored the water balance and lessened the 
acidosis, the baby seemed .so much better that 
we decided to operate. A high mid-line in- 
cision was made, and the ileum was found 
invaginated into the descending colon. By 
gentle pressure it was easily reduced. The 
abdomen was filled with salt solution and 
rapidly closed. The patient was on the table 
twenty minutes. He made an uneventful re- 
covery and left the hospital in nine days. 

This case is cited not to advertise the skil 
of the surgeon but to emphasize how des- 
perately ill these little ones can become in i 
short time, and yet respond rapidly to prope; 
treatment. A seven months old baby, ill fo 
thirty-six hours, abused with cathartics, de 
hydrated from loss of water and blood, wa 
apparently so near gone that the wisdom o 



March, 1940 



SURGERY UPON INFANTS— GRIFFITH 



131 



operating was doubtful. Yet after two hours 
of preparation he was able to withstand a 
general anesthetic and an abdominal opera- 
tion and to make a complete recovery. 

Intussusception is probably the most fre- 
quent surgical catastrophe in the abdomen 
of an infant. At least two-thirds of all cases 
occur under one year of age, and the ma- 
jority occur from about the fifth to the 
eighth month. It is several times more fre- 
quent in the male, and often seems to appear 
out of a clear sky in apparently healthy 
babies. There are several varieties, but the 
most common is the invagination of the 
ileum, cecum and appendix into the large 
bowel. The attacks usually appear suddenly 
and are manifested by severe abdominal 
pain. In fact the pain is so clear-cut, sud- 
den, and acute, that it has been compared to 
the onset of a ruptured ectopic pregnancy. 
The pain passes off quickly and the baby 
appears to be comfortable. Soon, however, 
the pain recurs followed by vomiting, dis- 
tention and tenesmus. Usually, but not al- 
ways, blood is mixed with the stools, but 
later there is only a blood-stained mucous 
discharge from the bowel. Diagnosis can be 
made almost from the history alone, even 
when there is no bleeding from the bowel. 
Usually an abdominal tumor soon appears on 
the right side, in the center, or even on the 
extreme left. The finger in the rectum may 
palpate a mass, but often when no mass is 
felt and even when there has been no previ- 
!ous bleeding from the bowels, there will be 
blood on the finger when it is withdrawn, 
in the rare case when a definite diagnosis of 
intussusception cannot be made, it is never- 
theless evident that an acute surgical condi- 
tion exists which demands operation. Un- 
fortunately, in the vast majority of cases, 
when first seen by the surgeon, the obstruc- 
tion is well advanced and the diagnosis only 
too obvious. 

In former years efforts were made to re- 
duce the obstruction by fluids introduced into 
the rectum. This I mention only to condemn. 
It is too uncertain, wastes valuable time and 
adds to the shock. The x-ray is unnecessary. 
At operation, reduction is usually easy if the 
ca.se is gotten within the first eighteen hours. 
In the late cases reduction down to the last 
few inches is seldom difficult, but complete 
reduction by manipulation alone is some- 
times impo.ssible. To leave the obstruction 
incompletely reduced is dangerous. To re- 



sect is almost invariably fatal. Probably the 
best solution is to incise the constricting 
band vertically just as you would cut the 
muscle of the pylorus in congenital stenosis, 
except that in these cases you cut completely 
into the lumen of the bowel, reduce the ob- 
struction and then suture the incision in the 
gut with the finest silk and close the abdo- 
men without drainage. That procedure is 
not as difficult or dangerous as it may seem, 
and has served me well in several cases. 

As a rule acute intussusception once re- 
duced does not recur. However, I recall one 
case in which I reduced by operation a 
simple intussusception in a baby eight 
months old. Less than a year later, while 
I was out of town, the intussusception re- 
curred and another surgeon operated. About 
six months later it again recurred, and then 
at operation I tacked the terminal ileum to 
the side of the cecum. The patient is now 
over twenty years old and has had no fur- 
ther trouble. I mention this case merely as 
a matter of interest, and not to recommend 
that the ileum be fixed by suture routinely. 

Meckel's Diverticulum 

Baby B., age three months, female, was 
admitted to the hospital with the history 
that twenty-four hours previously she de- 
veloped severe abdominal pain which would 
come and go, accompanied by marked vomit- 
ing. These symptoms increased in severity 
up to the time of admission. The mother 
stated that the abdomen was greatly swollen 
and that there had been neither diarrhea or 
marked constipation. The temperature was 
102°, pulse 120, respiration 30. Lungs were 
clear and heart normal except for the rapidi- 
ty. The abdomen was uniformly and great- 
ly distended — the typical drum-like appear- 
ance. It did not seem to be especially tender. 
No mass was felt on abdominal or rectal ex- 
amination. A right rectus incision was 
made. The appendix was normal. A Meck- 
el's diverticulum was found pressing on and 
constricting a loop of the small bowel. The 
diverticulum was removed almost flush with 
the ileum, and the opening in the intestine 
sutured longitudinally with a fine silk suture. 
The patient made an uneventful recovery 
and left the hospital in one week. 

Statistics from autopsies indicate that 
Meckel's diverticulum occurs in possibly 3 
per cent of individuals, yet I have heard 
surgeons of large experience state that they 



132 



NORTH CAROLINA MEDICAL JOURNAL 



Mareli. 1940 



rarely see one. The late Sir William Osier 
was in the habit of asking his students why 
it was that so frequently a physician in 
practice would state that he seldom saw such 
and such a sign in such and such a disease, 
when the text-books stated it was quite com- 
mon. After the students had made several 
unsuccessful stabs at a reply. Dr. Osier 
would answer, "It is because it was not 
looked for carefully." Obviously I do not 
recommend routine search for a Meckel's 
diverticulum when the abdomen of an infant 
is opened for some other cause. However, 
I do recommend it as a routine procedure in 
adults when feasible, and it is surprising 
how many times the search will be rewarded. 

Congenital Bands 

Baby F., age five weeks, male, was seen 
at his home by a very competent physician 
shortly after the onset of vomiting. Follow- 
ing consultation with a pediatrician the baby 
was brought at once to the hospital with a 
diagnosis of "something gone wrong in the 
abdomen which demands a surgeon". A mid- 
line incision revealed a loop of ileum bound 
down tightly by a band arising from the 
cecum and extending to the parietal perito- 
neum. This band was severed and the bowel 
found to be in good condition. Recovery was 
uneventful. 

Strictures causing partial or complete ob- 
struction, blind pouches and other congenital 
abnormalities of the small bowel, while not 
frequent, may occur in the practice of any 
surgeon. Usually they become manifest in 
the first few weeks of life. Rarely is the cor- 
rect diagnosis made, nor is that necessary, 
providing the need for exploration is recog- 
nized promptly. 

Congenital Pyloric Stenosis 
Baby A. B., age seven weeks, female, ad- 
mitted to the hospital with a history of 
vomiting and loss of weight. The presence 
of a typical olive-shaped mass in the region 
of the pylorus gave the diagnosis. After the 
usual examination and pre-operative prepa- 
ration by a pediatrician, a high right rectus 
incision was made under ether. The liver 
was retracted. A Fredet-Rammstedt opera- 
tion was performed. The patient left the 
table in good condition and was returned to 
the pediatrician for post-operative care. She 
made an uneventful recovery. 

Baby F. P., age three weeks, female, was 
admitted to the hospital from a neighboring 



town in an extremely emaciated condition. 
The history was that various forms of nour- 
ishment had been tried which merely in- 
creased the vomiting. The true diagnosis 
had not been suspected, although when the 
patient was admitted to the hospital, a small 
mass could be felt just below the right costal 
margin near the mid-line. Under the care 
of a pediatrician the baby improved rapid- 
ly, so that in about thirty-six hours opera- 
tion was advised. Because the baby was im- 
proving under treatment, the parents felt 
that operation was unnecessary and took her 
home to continue the treatment. About ten 
days later she was brought back in a worse 
condition than at her previous admission. 
Again the pediatrician attempted to get her 
in shape for operation, but with only fair 
success. Under local anesthesia a high right 
rectus incision was made, the liver retracted 
and the stomach found to be tremendously 
dilated. A Fredet-Rammstedt operation was 
done with excellent exposure of the mucosa. 
A few whiffs of ether was then given to 
facilitate closure. The patient left the table 
in fair condition but died forty-eight hours 
later. 

These two cases are cited for comparison. 
In the former the diagnosis was made 
promptly, and after the usual preliminary 
preparation a successful operation was per- 
formed with very little danger. In the latter 
the baby was not brought to the hospital 
until she was extremely emaciated and de- 
hydrated. Even when the condition was im- 
proved to the point where o))eration seemed 
ju.stified it was refused. 

The cases of simple pylorospasm recover 
under medical treatment, while in the cases 
of true stenosis attempted relief by medical 
means causes a loss of valuable time. Until 
recently some pediatricians believed that 
since the medical treatment, consisting large- 
ly of gastric lavage followed by feedings 
through the catheter, together with atropine 
or phenobarbital, would cure simple pyloro- 
spasm, it would also cure or relieve some of 
the cases of true stenosis. Most pediatricians 
now agree that when simple pylorospasm 
has been ruled out, and a definite diagnosis 
of true obstruction made, operation should 
be resorted to after proper preparation. 
Therefore the important point is the differ- 
entiation between the two conditions. In 
both there is projectile vomiting with defi- 
nite peristaltic waves visible over the epigas- 



March, 1940 



SURGERY UPON INFANTS— GRIFFITH 



133 



trium ; although in the true stenosis the 
amount of vomitus is somewhat more and 
the peristalsis more active. However, the 
difference in degree of those two symptoms 
is not sufficient to be relied on entirely in 
differential diagnosis. 

In pylorospasm there is only slight loss of 
weight, while in true obstruction the loss is 
usually marked. In pylorospasm the stools 
are practically normal, while in true pyloric 
obstruction they are scanty and composed 
largely of mucus. In pylorospasm obviously 
no tumor can be felt, wliile in true obstruc- 
tion a tumor can usually be felt, and if so, 
is pathognomonic. Usually the diagnosis of 
congenital pyloric stenosis can be made with- 
out the x-ray. If there be doubt, x-ray is 
helpful by showing the contrast medium 
present in the stomach after six to eight 
hours in the true obstructive cases in spite 
of vomiting, whereas in that length of time 
the stomach will be empty if there be no 
organic obstruction. Needless to say the 
stomach should be washed out immediately 
prior to operation. 

Acute Appendicitis 

Although acute appendicitis is seen fre- 
quently in children under three years of age, 
I have seen no case under one year. 

Imperforate Anus and Rectum 
The records of the out-patient department 
of the New York Lying In Hospital showed 
that imperforate anus occurred 27 times in 
93,000 births, or one in 3,500. Vernon David 
states that various authors give the inci- 
dence of malformation of the rectum and 
anus between 1 in 5,000 to 1 in 10,000. 

Baby J. S., male, was at birth apparently 
normal except that there was no anus, and 
no depression to indicate where it should 
have been. When he was seventeen hours 
old, under light ether by the open drop 
method, incision was made through the peri- 
neum back to the coccyx. The loose tissues 
were dissected upward for a distance of be- 
tween two and three inches, when the pal- 
pating finger detected an area of lessened 
resistance, and, on slightly more careful dis- 
section, the blind pouch of the rectum was 
seen. This was dissected loose and opened, 
and about two ounces of meconium escaped. 
The mucous membrane was then sutured to 
the skin at a location where we thought the 
anus should have been. Although the opera- 
tion lasted thirty minutes the little patient 



showed practically no signs of shock and 
made an excellent recovery. For one year 
after the operation the rectum was dilated 
periodically by inserting the little finger, in- 
dex finger and the thumb at each treatment. 
The family then returned to their home in 
Cuba. Nine years later the mother gave me 
a verbal report that the child was healthy in 
every way, and that so far as she knew the 
bowel function and sphincter control were 
normal. 

Obviously no one surgeon sees a sufficient 
number of congenital malformations of the 
rectum to draw any definite conclusions. It 
is only by a number reporting and pooling 
their cases that any helpful information can 
be obtained. 

Benign Tumors of the Liver 

Baby E. W., age four months, male, was 
brought from a neighboring town because of 
the fact that the abdomen had been enlarg- 
ing rather rapidly. On examination the baby 
seemed normal except that the abdomen was 
distended tremendously by a mass which on 
percussion gave dullness throughout the 
whole abdomen except for slight tympany in 
each fiank. A mid-line incision was made. 
A tumor which by actual weight was a trifle 
over three pounds was attached to the under 
surface of the liver by a small pedicle. The 
pedicle was severed between hemostats and 
the tumor easily removed. The rest of the 
abdomen was normal. The patient was on 
the table only a few minutes, and after the 
operation was in fair condition. On the third 
day he began to grow weaker and died on 
the fourth day. The specimen was sent to 
Dr. Winternitz, Professor of Pathology at 
Yale, who made a diagnosis of myxoma of 
the liver. Christopher in his recent book 
makes the following statement: "Benign 
tumors of the liver are of more interest to 
the pathologist than to the surgeon. Lipoma, 
fibroma and myoma have been reported but 
are e.xtremely rare, and adenoma occurs in- 
frequently." He does not mention myxoma, 
nor does the sy.stem of surgery edited by 
Dean Lewis mention benign tumors of the 
liver. This case is reported as one of ex- 
treme interest because of its rarity. 

Irreducible and Strangidated Inguinal 

Hernias 
Baby M., age three months, female, was 
admitted with the history that since birth 
the mother had noticed a swelling in the 



134 



NORTH CAROLINA MEDICAL JOURNAL 



Marcli. l;i40 



baby's groin which would come and go. For 
the past eight hours the mass had been pro- 
truding and could not be reduced. Examina- 
tion showed an apparently healthy child with 
a right inguinal hernia the size of a hickory 
nut and extremely tense. Under light ether 
a very tight ring was incised. The sac was 
opened and the hernia reduced. A high liga- 
tion of the sac was done and the wound 
closed. 

Baby R. B., age five weeks, male. History 
vi'as that on a few occasions since birth the 
mother had noticed a slight protrusion in the 
right groin. About four hours before ad- 
mission it was noticed that this mass had 
returned, was quite hard and could not be 
reduced. Examination showed a very tense 
mass the size of a large olive protruding 
from the right inguinal canal. Under ether 
an incision was made and a knuckle of bowel 
found tightly constricted. This was reduced, 
the sac dissected out and ligated high. The 
skin was then closed and a circumcision done. 

From the viewpoint of the surgeon, her- 
nias in infants may be placed in three 
groups : 

1. Those with symptoms of strangula- 
tion. These demand immediate operation. 
Unlike the dehydrated cases of intussuscep- 
tion and pyloric stenosis, they are usually in 
good condition and can be operated upon im- 
mediately after admission. These are real 
emergencies and a delay of a few hours may 
be disastrous. 

2. Those cases in which the hernia is ir- 
reducible but without evidence of strangula- 
tion. These are certainly urgent, and really 
should be classed as emergencies. While 
there may be no indication of beginning 
strangulation, it cannot be excluded definite- 
ly. Since the infant is in relatively good 
physical condition, there is nothing to be 
gained by delay. 

3. Those cases where the ring is large 
and the hernia protruding most of the time 
in spite of mechanical support. The.se are 
frequently bilateral. They could hardly be 
classed as urgent, but the results of opera- 
tion are so satisfactory that I feel we are 
justified in assuming the slight risk, rather 
than permit the ring to become more dilated 
and the infant to be handicapped constantly 
by the protruding mass. 

At opei-ation a high ligation of the sac is 
all that is necessary. To overlap or even to 
suture the fascia is unnecessary, and in- 



creases the danger of infection. Transplan- 
tation of the cord as in adults would be the 
height of folly. If there be an accompany- 
ing phimosis, circumcision should be done. 
I had selected from my records for dis- 
cussion cases of empyema, certain types of 
meningocele, tumor of the kidney, abdominal 
enlargement from hydronephrosis and va- 
rious fractures including those occurring at 
birth, but time would not permit. The ob- 
ject of this paper is to emphasize two cardi- 
nal points: 

1. That from a surgical standpoint, the 
infant is not a miniature adult, and what 
may be considered fair or even good surgery 
upon an adult may be poor or even bad 
surgery upon an infant. 

2. That many of these desperately ill in- 
fants may, by the aid of a competent pedia- 
trician, become reasonably safe operative 
risks, and precious lives may be saved. 



THE PREVENTION AND TREATMENT 

OF PELVIC FLOOR INJURIES 

B. P. Watson, M.D. (Edin.), 

F.R.C.S. (Edin.), F.A.C.S. 

Profes-.tor, Obstetrics and Gynecology, 

Columbia University 
Director, Sloane Hospital for Women, 

New York 

One of our prime aims in obstetric care is 
to ensure that our patient be left with no 
permanent disability of any kind after de- 
livery. One of the disabilities to which she 
is most liable is a lack of proper support 
of the pelvic organs resulting from over- 
stretching and laceration of tissues, sus- 
tained during the course of labor. The object 
of my short talk is to discuss how these in- 
juries occur, how they may be prevented, 
and how the.\- may be repaired when they 
are present. 

The discussion will have to be prefaced by 
a brief resume of the facts regarding the 
normal support of the pelvic organs. The 
maintenance of the pelvic organs in their 
normal position is jjrovided for in two ways 
— one by what may be called mesenteric sup- 
ports and the other by fascial and muscle 
sheaths and diaphragms. Thus the uterus is 
kept at its normal plane in the pelvis by be- j 
ing embedded at the level of the isthmus and 
the supravaginal cervix in a matrix of con- 



Read before the Section on Ovnecoloff^- and Obstetrics, Medi- 
cal Society of tlie Stale of North Carolina, Bermuda Cruise, 
May 10. 1939. 



March, 1940 



PELVIC FLOOR INJURIES— WATSON 



136 



nective tissue, which is specially condensed 
at the bases of the broad ligaments along the 
line of the uterine vessels as they run to and 
from the uterus to their origin and termina- 
tion in the internal iliac artei'y and vein near 
the lateral pelvic wall. This condensation of 
fibrous tissue round the uterine vessels con- 
stitutes the so-called transverse cervical or 
cardinal ligament on each side and is the 
part of the mesentery of the uterus which 
plays the greatest part in keeping it at its 
normal level in the pelvis. The rest of the 
mesentery is the upper part of the broad 
ligaments with the ovarian vessels, and, sec- 
ondarily, the round ligaments and the utero- 
sacral ligaments. All of these latter play a 
part in the maintenance of the position of 
the fundus as regards its anteversion and 
retroversion, but have comparatively little 
part in the maintenance of normal level. 
■ One of the most apt descriptions of uterine 

' supports is that given by Chipman, who 
likens the uterus to a person seated in a 
swing. The transverse cervical ligaments on 
each side at the bases of the broad ligaments 
constitute the seat of the swing on which the 
isthmus of the uterus sits. The cervix hangs 
free in the vagina like the swinger's legs, 
while the upper part of the broad ligaments 
and the round ligaments are like the ropes 
of the swing which the swinger holds to keep 
his forward and backward balance. 

But if the uterus had no further supports 
than these it would be pushed downward by 
intra-abdominal pressure. It requires in ad- 
dition to be buttressed from below, and this 
buttress is supplied by the pelvic floor, made 
up of muscle and various fascial layers and 
sheaths surrounding the vagina, the rectum, 
and the bladder. 

This pelvic floor or diaphragm is so ar- 
ranged that there is no continuous gap in 
the direct line of intra-abdominal pressure. 
Thus the axis of the vaginal tube is practi- 
cally at right angles to that of the uterus 
when the latter is in normal anteversion, 
so that any tendency for the uterus to be 
pushed down into the vagina is counteracted 
by the resistance of the posterior vaginal 
wall supported by the levator muscles and 
their fasciae. 

Proper pelvic floor support is dependent 
upon the maintenance of the normal direc- 
tion of the vaginal axis, and this is depend- 
ent on the integrity of the perineum and of 
the levator muscles and their fasciae. When 



the vaginal axis comes to be more nearly 
vertical than horizontal, the anterior vagi- 
nal wall, which has little support of its own, 
no longer has a firm shelf on which to rest, 
and it begins to sag downwards and back- 
wards, carrying the bladder with it as a 
cystocele. The cervix is dragged down, and if 
the uterus happens to be reti'overted its axis 
is now in a straight line with that of the 
vagina, and further descensus takes place. 
With cardinal ligaments of normal tone this 
descent of the uterus may take place slowly, 
and with intact pubo-cervical fascia the de- 
velopment of the cystocele may take time; 
but both will ultimately occur in some de- 
gree. When proper supports of these organs 
are also weakened, the development of the 
prolapse will take place more rapidly. 

The rectum is supported primarily by its 
fascia propria and secondarily by the leva- 
tor mu.scles and fasciae. If the latter are 
injured and not repaired, extra strain is 
thrown upon the former and a slow develop- 
ment of rectocele will occur. If both levator 
and fascia propria are injured, the rectocele 
will develop more rapidly and attain a larger 
size. 

Good levator and perineal support — which 
means a normal axis of the vagina — together 
with a normal anteversion of the uterus will 
ensure a maintenance of the latter at a fair 
level in the pelvis, even though its trans- 
verse cervical ligaments are somewhat re- 
laxed, and will prevent the development of 
a rectocele and of any large cystocele even 
if the fascia propria of the bladder has been 
injured. At the time of delivery there is 
never direct evidence of injury to the trans- 
verse cervical ligaments or to the bladder 
fascia ; and if there were, there is no tech- 
nique known for their immediate repair. 

On the other hand, tearing and injury to 
the levator muscles, the fascia propria of 
the rectum, and the perineal body and cen- 
tral raphe of the perineum are always evi- 
dent when present, and repair can be done 
at the time. The efficiency of this repair de- 
pends upon the correct approximation of 
the severed structures and the maintenance 
of this approximation during the healing 
process. 

This is not always ea.sy in the ordinary 
pelvic floor laceration. Let us try to visual- 
ize just what the common lesion is. The ordi- 
nary tear begins in the postero-lateral sulcus 
of the vagina on one or both sides. The point 



136 



NORTH CAROUXA MEDICAL JOURNAL 



March, 1940 



in the long axis of the vagina at which the 
tear begins varies. The higher this point is, 
the more extensive will be the damage to the 
levator structures. In the spontaneous de- 
livery or in a forceps extraction there is 
always an indication of when and where the 
tear begins. It is evidenced by that little 
trickle of blood which appears after a pain 
has passed off, or when the traction on the 
forceps is released. Up to that time there 
has been no bleeding. When bleeding ap- 
pears we know that a laceration has begun 
at the level at which the head is at the time. 
As the head descends naturally or by forceps 
traction, the tear extends down through the 
postero-lateral vaginal wall and into the lat- 
eral pelvic floor supports towards the vaginal 
orifice, becoming gradually more central, so 
that when it reaches the vaginal orifice it is 
in the middle line — and it is in this line that 
the perineum tears. If tears have begun in 
both lateral sulci the two meet close to the 
vaginal orifice, and there is only one almost 
central tear in the perineum. Usually in bi- 
lateral tears the apex of the one is higher 
than that of the other. 

It is not easy to effect a perfect repair of 
such a lesion, for there has been a tearing 
across of muscle fibres and of fascia on each 
side, and a great deal of retraction occurs. 
The large mass of the muscle retracts out- 
wards, leaving only a thin, rather feeble 
portion towards the middle on each side. 
Sutures, even when properly placed, are apt 
to cut out, with the result that, even with 
perfect healing of the skin perineum, a per- 
manent relaxation of the pelvic floor remains 
with subsequent prolapse. 

Consider now the so-called third degree 
tear. This usually occurs in the course of 
the delivery- of the aftercoming head in a 
breech, or in a precipitate delivery of the 
head through the vulva, where there has been 
no previous warning that laceration was be- 
ginning. This tear begins near the vaginal 
orifice and is practically dead center, so that 
as it goes through the perineum it e.xtends 
into the anal canal and divides the anal 
sphincter. I have seen patients years after 
such an unrepaired laceration, and although 
they have all the discomforts of lost sphincter 
control they have had no prolapse of any 
kind. The reason is that this is a superficial 
tear of the central raphe of the perineum: 
the levator muscles and fasciae on each side 



remain intact, so that they do not retract 
but continue to give support. 

All this leads up to the point I want to 
make — namely, that a modified central — or 
what may be called a medio-lateral episio- 
tomy. is preferable to the ordinary sponta- 
neous laceration and to the so-called lateral 
episiotomy. 

Let me describe just how a medio-lateral 
episiotomy is done on my service in the 
Sloane Hospital for Women. The procedure 
is carried out when the head or the breech 
is beginning to distend the perineum. It 
should be done before laceration of the va- 
gina has begun, as evidenced by the little 
trickle of blood which I mentioned. If this 
appears, the incision ought to be made with 
the next pain, irrespective of the degree of 
perineal distension. If forceps extraction is 
indicated, the forceps are applied and gentle 
traction is made to distend the perineum. 
With the perineum distended and tightened, 
either at the acme of the pain in a sponta- 
neous delivery, or by gentle forceps traction, 
an incision is made with the ordinary curved 
Mayo scissors, the scissors being placed with 
one blade inside the vagina and one outside 
on the perineum. Care must be taken to keep 
the handles of the scissors in the line of the 
central raphe of the perineum: otherwise a 
shelving cut will be made, and this must be 
avoided. The curve of the scissors is suffi- 
cient to carry the lower end of the incision 
to one side of the anal orifice and the 
sphincter. In the ordinary case the incision 
does not e.xtend as far as the level of the 
anus. 

A study of a dissection of the pelvic floor 
will show just what structures are cut. It 
will be seen that the incision goes through 
the center of the triangular ligament, and. 
in its deeper part, through the line where 
the two levator muscles and their fasciae 
merge in the middle line. If it reaches nearer 
the level of the anus, it is still between the 
transverse perinei muscles on each side, 
avoiding the sphincter, so that should ex- 
tension occur the latter will not be injured 
and the anal canal will not be entered. 

In delivering the head the same care must 
be exercised as in delivery through an intact 
perineum. Flexion of the head must be 
maintained until all of the occipital region is 
born, and extension allowed only as the rest 
of the head slips out. Too rapid extension 
mav result in further laceration. 



March, 1940 PELVIC FLOOR INJURIES— WATSON 137 

Repair of the Incision Hospital, the late Dr. William E. Studdiford, 
It is our custom to repair the incision be- and carried on and modified by his pupils- 
fore the birth of the placenta. The reasons notably by William M. Findley. 
for this are that the patient is still under On a service with interns coming and go- 
anesthesia : that we have time on our hands mg. breaks of established technique are apt 
after seeing that the baby is all right; and to occur. In going over our results for the 
that we have never seen anv injury to the year 1937 we found that we had had an un- 
repair resulting from the delivery of the "sual number of complete or partial break- 
placenta. If at any time bleeding should in- t'owns of repaired episiotomies. An investi- 
dicate that the placenta is separating, it is gation brought out the fact that the tech- 
delivered, and the repair then continued. mQue just detailed had not always been ac- 
A strip of sterile gauze or a sterile gauze curately followed. The matter was taken in 
wipe with string attached is placed in the hand and fresh instruction given, with the 
vagina above the apex of the incision to keep result that 1938 showed a decided improve- 
the field clear of blood. A pair of Allis ment. The figures for the two years are as 
clamps are placed on each side at the muco- follows : 
cutaneous junction, and used as retractors. ^^^^^ ^^ 2nd degree'fJceration 

Beginning at the apex in the posterior vagi- and episiotomy 584 

nal wall, a running suture of No. 1 chromic Cases in which some break-down 

catgut approximates the cut edges to just Ca"'eT7equ>rinff 'seconda^ ' ' ' ' °^ ■ " 

beyond the skin margin. This suture is not repair 9, or 1.6% 

tied, but is left long and is continued at a „ - „ . , ^?'^ ^■ 

, , , T J. I i.i 1 i Cases of 2nd degree laceration 

later stage as a subcuticular stitch to ap- oj. episiotomy 706 

proximate the skin edges. This .stitch in the Cases in which some break-down 

vaginal wall may be through and through, ca'^c's^requiring secondary " ' ' "' " '•''^"- 

or submucous from the beginning. repair 2, or 0.3% 

With the vaginal tube thus restored down When a break-down occurs, it usually 

to the skin of the perineum, the severed means a longer hospitalization of the patient, 

deeper structures are approximated by in- In 1937 there was a total of 177 extra hospi- 

terrupted figure of eight sutures of chromic tal days care given for this reason, while in 

catgut No. 2. As there is very little lateral 1938 there were only 50 days. This was a 

retraction of tissues, the sutures are easily saving of 127 hospital days, which at $4 a 

placed, and they do not tend to cut out. day meant a .saving to the hospital of $508. 

A running suture of No. 2 or No. 1 (Our ward patients are taken care of on a 

chromic, beginning anteriorly, approximates flat rate, irrespective of the time they may 

the superficial fascia. At the lower end of have to stay on the obstetrical service.) 

the incision the needle brings the suture out This experience brought home to us anew 

on the skin surface. the necessity for constant and close super- 

The running suture in the vaginal wall is vision of every detail of what we regard as 

now continued down as a subcuticular suture e.stablished procedures. 

approximating the skin edges, and is brought The test of any procedure is in the follow- 
out on the skin surface at the lower end op- up of the patients. I can say, unhesitatingly, 
posite the fascial stitch. These two sutures that the ultimate results as regards pelvic 
are then tied together over the lower end of floor support are better with a median episio- 
the incision. tomy and repair, as described, than after 

As an additional safeguard we may place spontaneous laceration with repair, and even 
a single stitch of silkworm gut near the after delivery without gross laceration, 
muco-cutaneous junction, and sometimes one, Our experience is that those patients who 
or even two more along the length of the have had median episiotomy and repair re- 
skin wound. In the event of a break-down quire the same procedure in subsequent de- 
of the catgut approximation these may liveries, whereas many who have had spon- 
obviate the necessity for a secondary repair, taneous lacerations and repair deliver sub- 
The method of closure may, of course, be sequently without further laceration. This 
varied in many ways. The method I describe may sound like a left-handed argument for 
has given us the best results. It is the episiotomy but it really is not; for it means 
method used by my predecessor in the Sloane that when properly done the procedure re- 



138 



NORTH CAROUXA MEDICAL JOURNAL 



March, 1940 



stores the patient to her original nulliparous 
condition so far as her pelvic floor supports 
are concerned. 

But episiotomy does still more than that. 
It saves the child from injury by shortening 
the period during which the head pounds on 
the perineum : and, by allowing the head to 
slip back at the outlet, it takes the strain off 
the fascial structures anteriorly — notably 
the fascia propria of the bladder — and mini- 
mizes the risk of cystocele developing. 

With a perfect result so far as the pelvic 
floor is concerned we have still another re- 
sponsibility- to our patient — namely, to see 
to it that the uterus during its involution re- 
turns to its normal anteverted position. Up 
to the tenth or twelfth day of the puerperium 
it is prevented from retroverting because it 
is supported posteriorly by the lumbar spine 
and the promontory of the sacrum. After 
this, as it descends below the pelvic brim, it 
is quite apt to tilt backwards. It should be 
a rule, therefore, to examine bimanually 
every patient on the twelfth or fourteenth 
day of the puerperium. If the uterus is 
found to be retroverted. it can then be very 
easily replaced and held in place with a 
pessary, which is left in until involution is 
complete at the end of six weeks. We fur- 
ther make it a rule that every patient be ex- 
amined bimanually at the end of the fourth 
week of the puerperium, as we not infre- 
quently find that a uterus, in perfect position 
at the end of the second week, has become 
retroverted by the fourth. If such be the 
case, the uterus is replaced and a pessary 
inserted. 

If the uterus is thus kept anteverted all 
strain is taken off its fascial and ligamentous 
supports. These will involute normall.v, and 
so retain it in proper position when the pes- 
sary is removed. If replacement and reten- 
tion are not effected before the end of the 
six-week period of involution, the retrover- 
sion will be permanent. We have found the 
use of a pessary in this way much more cer- 
tain in its results that the use of the knee- 
chest position, or of exercises like the monkey 
crawl. 

It has been objected that there may be 
risk of infection in introducing a foreign 
body into the vagina so early. All I can say 
is that over a period of many years I have 
never seen infection occur. 

Another very valid objection is that in 
introducing the pessary we would cause a 



great deal of pain and might disrupt a re- 
cently repaired pelvic floor. This objection 
is done away with by the pessary devised by 
my colleague. Dr. William M. Findley. It is 
an ordinary Smith-Hodge hard rubtier pes- 
sary, with a small section of .'^oft rubber let 
into each pole. With this device the pessary 
can be folded on itself and be introduced 
through the narrowest vaginal orifice with- 
out pain and without injury to any recent 
wound. When in the vagina it expands to 
its normal shape. I commend this pessary 
to you not only for your puerperal patients, 
but for every case that requires pessary 
treatment. 



A 



TUBERCULOSIS CASE-FIXDIXG 
PROGRAM IX A WOMAX'S 
COLLEGE 

Ruth M. Collings. M.D. 

Greensboro 



When one looks at so long and complicated 
a title as that which has been assigned to 
me. it makes one feel that emphasis put on 
a word here or there might make this very 
complex subject more interesting and less 
diffuse. At first glance the most important 
word in this subject might seem to be 
"Woman's", for certainly it is not hard to 
see that the tuberculosis problem in a 
woman's college is at once more vital and 
more acute, because of increased suscepti- 
bility of the students, and also more difficult, , 
because of the nervous reactions of the 
adolescent girl. These factors, and particu- 
larly the second, I will discuss briefly in this 
paper. But on second thought I find mv eye 
and mind clinging to the phrase "Case Find- 
ing". Surely here is the crucial point. How 
shall we find tuberculosis where it exists hid- 
den and obscure? How bring it out into the 
open before the signs are so clear that "he 
who runs may read" — and weep? 

It is not necessary, before this audience, to , 
belabor the point which has time and again 
been emphasized to college presidents and 
deans, namely that if early cases of tubercu- 
losis are not sought with diligence, care, and 
by most skillful and modern methods, they 
will not be found. However, a brief resume 
of the data submitted by the Tuberculosis 

Fmm the Department of Health. WoinanV College. Universitv 
of Xorth Carolina. Read before the Section on Practice of 
Medicine. Medical Society of the State of North Carolina. 
Berrnufla Meeting. May IS. 1PS9. 



March. 1940 



CASE-FINDING PROGRAM— COLUNGS 



1^9 



I 



Committee of the American Student Health 
Association will serve to give added proof to 
a maxim which we all accept. 

This committee, which under the chair- 
manship, first of Dr. Lee Ferguson of West- 
ern Reserve University, and later of Dr. 
Charles E. Lyght of Carleton College, has 
done yeoman service in stimulating college 
health departments and college administra- 
tors to an appreciation of their duties and 
opportunities in tuberculosis work, published 
its first report in December, 1933. In that 
report only twenty-five colleges had been 
questioned as to their tuberculosis case-find- 
ing programs, and these were supposedly 
leaders in college health work. Of the 
twenty-five, only fourteen made any report, 
and of these only eleven gave data accurate 
enough to be serviceable as to their proced- 
ures and findings. 

On the basis of the reports from these 
eleven institutions, however, the same com- 
parisons can be made as those on the 1938 
report of the committee, in which 233 col- 
leges co-operated. It was found that seven 
of the eleven institutions reporting in 1933 
had what might be termed a fairly adequate 
tuberculosis case-finding program, by which 
is meant that these schools did not depend 
entirely on symptoms or even on physical 
signs for their diagnosis, but went after the 
cases with tuberculin testing, x-ray, or both, 
while four had no such definite machinery 
set up for this work. In the seven schools 
with an adequate program 262 cases of adult 
type, infiltrating pulmonary tuberculosis 
were found in a total student population of 
38,932. This is a rate of .67 per cent. In the 
four schools having no program, on the oth- 
er hand, only eleven cases were found in a 
student population of 15,374, or a case rate 
of .07 per cent. In other words, almost ten 
times as many cases, pi-oportionately, of in- 
filtrating pulmonary tuberculosis were 
found in institutions which were alive to the 
necessity of seeking for them. 

In 1934 the same fourteen institutions 
were asked for data as in 1933, with a case 
rate of .59 per cent for those with an active 
program as against .14 per cent for those 
without such a program. 

In 1935 the figures were .57 per cent 
against .12 per cent, with many more col- 
leges responding; in 1936 .42 per cent 
against .18 per cent; in 1937 .34 per cent 



against .11 per cent; and in 1938 .22 per 
cent against .01 per cent, with a student 
population of 261,949 in the institutions 
where an active search for tuberculosis was 
going on. 

Of course these figures indicate other 
things beside the incontrovertible fact 
which they show so clearly — namely, that 
through the years of this study, from three 
to twenty times as much infiltrating pulmo- 
nary tuberculosis has been found among col- 
lege students subjected to a real case find- 
ing program as in those among whom no 
such eflfort has been made. They also indi- 
cate a gradual and steady decline in the 
amount of tuberculosis present in college 
students, and an almost equally encouraging 
increase in the number of institutions which 
are alive to the problem and actively en- 
gaged in its solution. 

Our own experience with a case finding 
program at the Woman's College of the 
University of North Carolina began in the 
spring of 1932, when under the enthusiastic 
leadership of Dr. Anna M. Gove, then head 
of the college health department, and with 
the active assistance and inspiration of Dr. 
P. P. McCain of the North Carolina Sana- 
torium, the first tuberculosis clinic was 
launched. At that time it was impossible to 
get the full co-operation of students because 
the idea was so new, and pioneer educational 
work had to be done. However, in spite of 
the fact that we were successful in getting 
less than half of our positive tuberculin re- 
actors to have an x-ray of the chest, five 
cases of adult type pulmonary tuberculosis 
were found in a student body of 1608, or a 
case rate of .31 per cent. 

Following that initial experiment with the 
whole student body, we have carried out a 
program which has varied somewhat in 
method from time to time, but which has 
aimed at a case-finding survey — largely com- 
pulsory — of all entering students, and a 
more or less voluntary survey of the gradu- 
ating class. We are not under any illusion 
that this is the best program which could 
be evolved from the ideal public health 
standpoint. It has many shortcomings, of 
which probably the most glaring is that only 
entering students are involved in a com- 
pulsory survey. But in spite of these faults 
we have been able to make a diagnosis of 
adult type pulmonary tuberculosis in our en- 



140 



NORTH CAROLINA MEDICAL JOURNAL 



March. I'.MO 



tering classes varying from .49 per cent in 
1935 to .24 per cent in 1938. While no com- 
pletely accurate data are available, I can say 
from my own experience, dating from 1925, 
that the diagnoses of pulmonary tuberculosis 
made on our students before 1932, when this 
program was inaugurated, were practically 
nil. 

Our figures then, coupled with those pre- 
viously quoted from the whole group of col- 
leges, make absolutely ridiculous quotations 
from letters received by the Tuberculosis 
Committee of the American Student Health 
Association, from colleges where there is no 
case-finding program. I take the liberty of 
repeating a few of these quotations taken 
from the 1938 report of the committee. 

"I beg to advise you that we have no 
tuberculosis in College." 

"From my knowledge and experience of 
the place I would say that tuberculosis is not 
in any way a part here." 

"Our students come from only the best 
homes. We do not have any cases of tuber- 
culosis." 

This brings us naturally to the subject of 
methods, which, while not so interesting as 
that of results, is of the utmost importance 
in a program of this kind. In order to be as 
simple and direct as possible, I will state 
briefly what our methods have been in the 
past, and what they are at present; and 
then try to evaluate briefly the various 
changes made, and perhaps come to the de- 
fense of our present method of the universal 
chest x-ray, which may seem to many of you 
to require considerable defense. 

In 1932, when the program was first in- 
augurated, we attempted to do a Mantoux 
skin test, using a dosage of .1 cc. of 1/1000 
0. T. on every student. While this was never 
entirely possible, owing to the fact that there 
was objection to the test on the part of a 
very few parents, but more particularly be- 
cause we were never able to get quite one 
hundred per cent co-operation from the stu- 
dents in reporting back to the physicians to 
show the result of their skin tests, we soon 
reached the point where a very large per- 
centage — almost one hundred per cent — of 
our students were having Mantoux tests 
made and interpreted. The intradermal in- 
jections were made at the college gymnasi- 
um, where the students were registering for 
the first semester, and the tests were read 



at the Infirmary forty-eight hours later. All 
positive reactors were sent for and asked to 
sign up for chest x-rays, for which they were 
at first charged $2.00, then $1.50, and later 
$1.00 in addition to their regular medical 
fee. These plates were at first made at the 
Guilford County Sanatorium, but in 1934, 
with the purchase of x-ray equipment by the 
college, they were made in our Physics De- 
partment, in connection with a course for 
laboratory technicians being given by that 
department. A good deal of pressure was 
put upon positive reactors to have films 
taken ; but while we found it much easier to 
induce students to have x-rays made right 
on the campus than when there was the 
difficulty of transportation to the Sanatori- 
um, we were never entirely successful in 
obtaining their co-operation. However the 
percentage of films made of positive reactors 
constantly increased, so that while there 
were less than 50 per cent taken in 1932, by 
1935 there were 94 per cent. I might say 
parenthetically that these percentages cor- 
respond rather favorably with those ob- 
tained in other colleges where this method 
is used. During all this time the plates were 
read by the staff of the North Carolina State 
Sanatorium, who by their active co-opera- 
tion have made all this work possible. 

In 1937 we changed our method to that of 
requiring a chest x-ray of every entering 
student without attempting a Mantoux test 
on any of them. The universality of this 
procedure made it possible to collect the fee 
with the tuition, thus obviating the objection 
of the individual student to expending a dol- 
lar, more or less voluntarily, for an object 
which she often chose to consider useless. 
It was therefore much easier to get complete 
coverage of the entering classes, and we 
have been successful in this for the past two 
years. In 1937 these plates were all sent to 
the State Sanatorium for examination ; but 
with almost 900 entering students, this pro- 
cedure imposed an unbearably heavy burden 
upon the staff. So in 1938 we examined all 
plates ourselves, eliminating thereby the 
obviously negative ones, and sending to the 
Sanatorium physicians only such films as 
seemed to us possibly suspicious of tubercu- 
lous involvement. 

When reports come back on these plates 
from the Sanatorium, it is our custom to 
send form letters to all students having 



March, 1910 



CASE-FINDING PROGRAM— COLLINGS 



141 



negative films congratulating them on that 
fact. Those showing either Ghon tubercles 
or calcified glands, and those showing adult 
infiltration are interviewed personall}', the 
lesion found is carefully explained to them, 
and advice given them as to the future con- 
duct of their case, if any seems necessary. 
Letters are also sent to the parents of all 
students having any positive lesion, in which 
as full an explanation of the condition as 
possible is given. Personal interviews with 
the parents are suggested, if the lesion seems 
to be at all serious or active, and many 
parents themselves seek such interviews con- 
cerning their daughters' reports. It is al- 
ways urged that the letters be shown to the 
family physician, that the case be fully dis- 
cussed with him, and that the student her- 
self go to him for examination and advice, 
taking the x-ray film with her. A very few 
of our students have had lesions extensive 
or active enough to require Sanatorium 
treatment, and all other cases have been fol- 
lowed carefully here at the college, with fre- 
quent x-rays, temperature records, sputum 
examinations, etc., as the occasion demands. 
Tuberculin tests are done on students with 
positive x-ray findings, and occasionally 
show negative reactions. Such a condition 
of course calls for further study of the stu- 
dent and of her x-ray plates, and for further 
and heavier tuberculin dosage. 

We have never made the examination of 
the entire senior class as compulsory a mat- 
ter as that of the freshmen. Differing 
amounts of pressure have been put on the 
seniors from year to year with varying re- 
sults, but with never more than a rather 
small percentage responding. As we all re- 
member, dollar bills are hard things to come 
by near the end of one's senior year in col- 
lege, and this is particularly true in a 
woman's college. Moreover, most of our 
seniors have been reasonably healthy for the 
four years they have been under our obser- 
vation, and many of them have gained 
weight. Symptomless, excessively occupied 
with the social and academic whirl that 
makes up the modern college, and usually 
poor as Job's turkey, a senior is not easily 
persuaded to invest her time and her dollar 
in an x-ray of her chest. 

This year I thought it would be both in- 
teresting and educational — chiefly to myself 
— to see what an appeal to reason, without 



other pressure, would do for this situation. 
Accordingly, I wrote a letter, explaining as 
carefully and clearly as possible, exactly why 
it seemed to us wise for young women about 
to graduate from college to take advantage 
of the opportunity offered them for a chest 
x-ray at an exceedingly reasonable price. 
The letter ended with the simple but wistful 
hope that they would see the situation as I 
did and come to the Infirmary and sign for 
x-rays. With nothing more than this, almost 
exactly one-third of the approximately 400 
seniors responded to this letter and had 
chest plates made. Not good, you say ! Well, 
not bad either, I think, considering all the 
factors involved. A few more in whom for 
some reason x-rays seemed particularly 
necessary were later interviewed, and as a 
result have had plates made. But the first 
group were entirely uncoerced. 

It is probable that in the future we should 
make x-ray examination as hard and fast a 
rule for seniors as for freshmen. Indeed the 
fact that the senior is at a more vulnerable 
age than the freshman would make this 
seem most necessary. However, our present 
method might be called an educational ex- 
periment, which perhaps has some inherent 
value of its own. 

Finally, let us return to an evaluation of 
the two methods of examination which we 
have tried at this college, and which have 
each been used at different colleges — namely 
tuberculin skin testing with the x-ray ex- 
amination of positives vs. the primary x-ray- 
ing of each student without preliminary skin 
testing. Let me say first of all that "evalu- 
ation" is far too ambitious a term for me to 
use at this point. Indeed, it is doubtful if 
a true evaluation could be made by anyone, 
given the limited and confusing data which 
we have at present; and certainly my ex- 
tremely limited knowledge of the diagnosis 
of tuberculosis would make such an attempt 
valueless and even pretentious on my part. 
My excuse then, for embarking upon this 
subject at all, is that a brief resume of the 
arguments pro and con, and some record of 
the results obtained by us and by others 
with the two methods, might serve to stimu- 
late a real fact-finding program along this 
line. 

First, then, it would seem that the infalli- 
bility of the Mantoux test as a criterion of 
tuberculous infection must be more nearly 



142 



NORTH CAROLINA MEDICAL JOURNAL 



Mart-h. 1940 



established or disproved by unbiased data. 
If it is possible for persons who suffer from 
a tuberculous infection to show negative in- 
tradermal skin tests, then we may be pass- 
ing up cases of tuberculosis unless we x-raj' 
each individual in the group. Of course we 
are all aware that a severe or overwhelming 
tuberculous infection as well as certain other 
acute infections occasionally result in a neg- 
ative Mantoux test. But these conditions are 
not apt to be very common or confusing in 
routine college health examinations. 

On the other hand, there are some indica- 
tions in recent publications that routine 
tuberculin testing is often far from infalli- 
ble. For instance, a paper in the January 
1939 issue of the American Journal of Pub- 
lic Health, written by Drs. Lusden, Bear- 
ing, and Brown, of the U. S. Public 
Health Service, shows first, the wide varia- 
tion in percentage of postive reactors, from 
10.2 per cent up to 88.6 per cent, depend- 
ing on the preparation and dosage of tuber- 
culin used; and, second, throws discredit on 
any tuberculin testing program, by show- 
ing that in Giles County, Tennessee, of 12 
.school children who showed pulmonary le- 
sions, regarded as clinically significant, 7 
were negative and 5 positive to a routine in- 
tradermal test with a standardized com- 
mercial P. P. D. in a dosage considered ade- 
quate by such an eminent authority as Dr. 
Esmond Long of the Henry Phipps Institute. 

Figures not quite so damning to the tuber- 
culin test, but which still tend to throw con- 
siderable doubt on results, at least with the 
average dosage of Old Tuberculin, were edi- 
torially discussed June 18, 1932, in the Jour- 
nal of the American Medical Association. 
The data were taken from a report of P. D. 
Hart to the Medical Research Council of 
London, in the same year. He had studied 
1030 clinically tuberculous patients of all 
ages, and found that 38, or 3.7 per cent 
failed to react to .1 cc. dosage of a 1/1000 
solution of O. T., which is the average dose, 
and that 2.7 per cent were negative even to 
.1 cc. dosage of a 1/100 solution. 

In addition the records of the Tuberculosis 
Committee of the American Student Health 
Association show that in the year 1937, 
when separate records were kept for col- 
leges using different methods of case-find- 
ing, .3 per cent adult type cases were found 
in colleges which used the combined methods 



of skin testing and x-ray, whereas .7 per 
cent cases were found in the colleges with 
a universal program of x-rays. In other 
words, case-finding was over twice as suc- 
cessful when each student was .x-rayed re- 
gardle.ss of his tuberculin test. 

Of course a good deal of this argument 
might be eliminated if an adequate, and at 
the same time safe dosage of tuberculin 
could be agreed upon by all authorities. At 
present the two dose method with P. P. D. 
seems to be the most favored, and to meet 
best the qualifications of adequacy and safe- 
ty. But here we are brought face to face 
with the untold practical difficulties, which 
every college that has tried this method has 
met, in administering two doses of this ma- 
terial to a large group of students. For my 
own part it seems to me almost impossible 
to obtain enough student co-operation in the 
administration and reading of two separate 
doses to make it practical at all. After all. 
important as it is, tuberculosis case-finding 
is only part of our job as student health 
physicians, and the time and effort involved 
in such a program would take an overwhelm- 
ing amount of the energy which we need to 
devote to the whole problem of student 
health. 

In answer to such data and argument 
about the reliability of tuberculin testing, 
those who advocate such testing as the most 
important ca.se-finding procedure (and they 
include excellent tuberculosis specialists) 
point to the fact that only by some form of 
tuberculin testing is it possible really to in- 
dicate to a student whether she has ever had 
a tuberculous infection. We all know and 
admit that many such infections leave no 
calcified areas in the lungs, detectable by x- 
ray examination. They say too, and truly, 
that very important information is obtain- 
able by a negative tuberculin test in the 
freshman year, with a positive test in a sub- 
sequent year — information as to contacts, 
etc.. which is obtainable in no other way. 
And all this might easily be missed without 
the tuberculin test. 

Other arguments and other data might 
easily be added by the advocates of each of 
these methods. The controversy rages, and 
those of us who deal practically with the 
problem in the colleges await authoritative 
research on the whole problem. I note with 
encouragement that at the next meeting of 



Mai-ch, 1940 



ACETANILID POISONING— McINTOSH 



143 



the National Tuberculosis Association, to be 
held in Boston in June of this year, there 
will be a symposium on the subject, "Mass 
Tuberculin Testing and X-Raying — A Re- 
view of the Present Status", and that one 
paper in that symposium is to be on "Tuber- 
culin" by Dr. Esmond Long, Director of the 
Henry Phipps Institute, and a second is on 
"X-Ray Findings in Negative and Positive 
Reactors", by Dr. Bruce H. Douglas, Tuber- 
culosis Controller of the Detroit Department 
of Health. It would seem probable that sta- 
tistics which might be offered, particularly 
by Dr. Douglas, on the extensive work done 
in Detroit during the last two years, would 
go far to solve some of the problems which I 
have tried to raise in this paper and which 
have long troubled the minds of all public 
health administrators. 

In the meantime I suppose most of us will 
go on as we have been doing, undertaking 
the type of program which seems to us most 
practical, considering equipment and staff, 
and which also seems to us relatively effici- 
ent in finding cases of tuberculosis. Thus 
we note that several universities with large 
medical staffs, who can employ expert 
roentgenologists and have adequate fluoro- 
scopic equipment, are relying on the fluoro- 
scope to act as a screen in the detection of 
cases, following this with flat or stereoscopic 
plates in suspicious cases. More of the 
women's colleges are using x-ray methods 
than are the men's colleges, and I suspect 
that, as with us, the emotional difl^culties 
incident to tuberculin testing in young 
women, caused the preference for the uni- 
versal x-rays. 

Thus it can be seen that this problem of 
finding cases of tuberculosis in college stu- 
dents is far from a simple one. We want 
you to know its complexities and difficulties. 
If this rather wandering and far from con- 
clusive paper has helped to give you, the 
physicians of our students, a sympathetic 
understanding of our problems and how we 
are attempting to meet them, it may be 
worth while to have presented it to you. 

Discussion 

DR. J. H. McNeill (North Wilkesboro>: Our 
county is using a case-finding: method which is out- 
lined by the state of North Carolina. Among the 
children of school age, tuberculin testing is done on 
all children who show an undei-weight of 10 ner 
cent or more. Positive reactors are x-rayed. Un- 



fortunately, the county has no money to pay for 
such x-rays and the family has to do so, at the 
full rate whenever they can, and at charity rates 
otherwise at our local hospital. 

Our next effort to find tuberculosis Is through 
the fluoroscopic clinic also offered by the state and 
held yearly. We make a strenuous effort to have 
any person who has any contact whatsoever with 
tuberculosis to have a fluoroscopic examination, and 
if anything significant is seen there, to have chest 
films made. 

In that way we have been able to pick up quite 
a good many cases which otherwise would probably 
have gone on to full active tuberculosis. I thorough- 
ly agree with Dr. Collings that the diagnosis must 
be made early and soon. I don't know who it was 
that said that early tuberculosis should be seen and 
not heard. 

CHAIRMAN YODER: Early tuberculosis must 
be seen and cannot be heard. 



CHRONIC ACETANILID POISONING 
WITH ADDICTION 

Donald McIntosh, Jr., M.D. 

Marion 

The toxicity of acetanilid in excessive 
do.sages and the clinical picture of acute and 
chronic acetanilid poisoning with addiction 
have been recognized by the medical profes- 
sion since the introduction of the drug as 
an antipyretic in 1886. As early as 1895 
case reports <•' of acetanilid poisoning be- 
gan to appear in the medical literature. Ex- 
tensive use by the profession, and the early 
introduction of the drug to the laity in the 
form of various proprietary nostrums and 
headache powders, soon led to a large num- 
ber of case reports of acetanilid poisoning 
Austin and Larrabee<-', Sutherland*'", Robin- 
.son'", and Quigley'", reported cases of 
son<", and Quingley"', reported cases of 
acetanilid poisoning, and expressed their dis- 
approval of the widespread use of the many 



Re^cl before the Section on General Pr>i^«=f.' .^fJj^J-' „®°?i|^ 
of ttie State of North Carolina, Bermuda Cruise, May 10, 1939. 

1. Rosenberger, R. C: A Case of Acetanilid 
Poisoning with Recovery, Phila. Polyclinic 
4:460, 1895. 

2 Austin, A. E., and Larrabee, R. C: Acetanilid 
Poisoning from the Use of Proprftary Head- 
ache Powders, J.A.M.A. 46:1680, (June 2) 1906. 

.3. Sutherland, E. L.: Acetanilid P°iso"™f' ^«<^'- 
cal Sentinel, Portland, Oregon 14:466, 1905. 

4. Robinson, W. J.: Impotence Caused by Exces- 
sive Consumption of Bromo-Seltzer, J.A.M.A. 
47:508, (August 18) 1906. 

5 Ouielev D. F.: Acetanilid in Bromo-Seltzer, 
J.A M.A. 46:454. (March 24) 1906, 



144 



NORTH CAROLINA MEDICAL JOURNAL 



March, 1940 



nostrums and proprietary powders. Nad- 
ler'", Stengel'", Fisher'"', and many others 
have stressed the strong habit producing 
qualities of the drug. Excellent experiment- 
al and clinical studies on the physiological 
effect of acetanilid have been made <", <"", 
<"'. Today, however, I feel that few of us 
realize the true proportions of the problem 
of drug poisoning, and certainly the current 
literature is not indicative of the extent of 
the problems arising from addiction to ace- 
tanilid. 

Acetanilid belongs to the group of so- 
called "coal-tar antipyretics" and occurs as 
a white powder or crystals. It is very cheap 
and can be bought in bulk for about thirty 
cents per pound. Because of its relative in- 
solubility, it is usually dispensed in powder 
or tablet form. Hale"-' has shown experi- 
mentally that the addition of sodium bicar- 
bonate decreases the toxicity of the drug, 
while caffeine tends to increase it. 

Acetanilid is used as an antipyretic, an 
analgesic, and locally as an ointment or dust- 
ing powder in various skin diseases. The 
less toxic coal-tar derivatives, such as phen- 
acetin, and the salicylates are now thought 
to be more suitable as antipyretics, and have 
largely supplanted its use. It is rarely used 
locally now because of the dangers of toxic 
absorption. Herricks and Irons''-'^', Gart- 
man and Ball, and Rosenberger"' reported 
cases of acetanilid poisoning from local ab- 
sorption. 

Acetanilid is now used chiefly as an anal- 
gesic agent. The drug is remarkably effici- 
ent and quick in relieving pain, and in simi- 
lar doses is apparently more powerful than 
the other coal-tar preparations. Acetanilid 

6. Nadler, W. H.: Acetanilid Addiction: A Re- 
port of a Case, J.A.M.A. 74:1717, (June 19) 
1920. 

7. Stengel, A.: Chronic Acetanilid Poisoning: Re- 
port of Two Addiction Cases, J.A.M.A. 45:243- 
245, 1905. 

8. Fisher, L. C: Chronic Acetanilid Poisoning, 
J.A.M.A. 100:736, (March 11) 193.3. 

9. Lowy, 0., and Helms, S. T.: Study of the 
Physiological Effect of Acetanilid on Human 
Subjects, Medical Record 140:561. 

10. Yound and Wilson: Toxicological and Hema- 
tological Studies of Acetanilid Poisoning, Jour, 
of Pharm. and Exper. Therap. 27:133. 1926. 

11. Payne: Acetanilid Poisoning: A Clinical and 
Experimental Study. Jour, of Pharm. and 
Exper. Therap. .')3:401. 1935. 

12. Hale: The Cyclopedia of Medicine, Vol. I: 48. 
12 A. Herricks and Irons: Chronic Acetanilid Poison- 
ing, J.A.M.A. 46-351, 1906. 

14. Summers: A Case of Acetanilid Poisoning, 
N. Y. Med. J. 71:426, 1900. 



is especially useful in the neuralgic or mus- 
cular types of pain. Headaches and migraine 
can sometimes be better controlled with it 
than with other drugs. Traumatic pain is 
not so effectively combated. Sodium bromide 
enhances the sedative effect on the cerebrum, 
and the combination of codeine and acetani- 
lid often shows an analgesic action compar- 
able to that of morphine. 

I wish to stress the fact that acetanilid, 
dispensed in ordinary therapeutic doses by 
reputable physicians who understand the 
possibilities of toxic effects and the tendency 
to habituation, is a useful and comparatively 
safe drug. Lowy and Helms'" and others 
have shown through careful animal and 
human experiments that the drug in ordi- 
nary doses does not have any deleterious or 
permanent effect on the body. 

Acetanilid in excessive amounts or in sus- 
ceptible persons acts as a powerful poison. 
The poisoning occurs in both the acute and 
chronic forms, and numerous deaths have 
been reported. Kebler, Morgan, and Rupp'"' 
discussed the result of a questionnaire to 
288 physicians, and found that 219, or 76 
per cent, had observed in.stances of acetani- 
lid poisoning. Of the 614 cases reported by 
these physicians, there were 17 deaths, some 
occurring from doses as low as lio grains 
in infants and 20 grains in adults. Sum- 
mers"^' reports a case of .severe poisoning 
following the administration of 8 grains of 
acetanilid for relief of headache. Quigley"' 
reported severe poisoning from a single dose 
of Bromo-Seltzer, and Tyrell's"'' patient 
barely escaped death from one dram of 
acetanilid powder. 

The onset of acute poisoning is rapid and 
may quickly assume alarming proportions. 
The outstanding features are deep cyanosis 
of the lips and entire body, and the symptoms 
of collapse. The temperature drops to sub- 
normal and there is marked sweating and 
prostration; the respiration is slow and shal- 
low; the pulse weak and rapid with irregu- 
larities. Coma and cardiac arrest soon fol- 
low. 

Chronic poisoning is at times more diffi- 
cult to detect, because in some patients the 
symptoms are not pronounced, and because 
patients addicted to the use of acetanilid 

13. Kebler. Morgan, and Rupp: The Cyclopedia of 

Medicine, Vol. I: 51. 
15. Tyrell: Acute Acetanilid Poisoning, J.A.M.A. 

46:956, 1906. 



March, 1940 



ACETANIUD POISONING— McINTOSH 



146 



often try to conceal or minimize their afflic- 
tion. 

The symptoms of chronic poisoning usual- 
ly follow a definite pattern, and produce a 
symptom complex which Gardinier""' states 
is diagnostic of the condition. Certainly, ex- 
amination of the various case reports reveals 
a marked similarity of symptoms and physi- 
cal findings. The onset of symptoms is 
usually gradual and they are often obscured 
by the complaints or symptoms for which 
the acetanilid was originally taken. The 
most striking symptom is marked cyanosis, 
which is most noticeable at the lips, mucous 
membranes, nose, lobes of the ears, and the 
fingers. There is usually some degree of 
anemia, so that the skin has a pale, bluish 
color. General weakness, easy fatigability, 
palpitation and dyspnea are constant com- 
plaints. The appetite is poor, and various 
digestive disturbances are common. Consti- 
pation alternating with diarrhea is often 
seen. Nervous excitability has been de- 
scribed, but as a rule the patients are rather 
dull and apathetic, with a tendency to in- 
somnia. The pulse is fast and compressible. 
Enlargement of the heart, spleen, and liver 
has frequently been noticed <"" <"'. 

Most investigators agree that there is a 
definite anemia due to the destructive action 
of the acetanilid on the red corpuscles. 
Payne'"> found that the initial action of the 
drug is destructive, producing a severe 
anemia; but with prolonged administration, 
there is excessive stimulation of the blood 
forming organs, and the rate of red cell 
formation may be greater than the obstruc- 
tive rate, thus producing a relative increase 
in the red count and hemoglobin. The white 
blood cell may be aflFected also. Kracke""' 
observed a case of agranulocytosis resulting 
from acetanilid. The blood uniformly ap- 
pears dark or chocolate color in this type of 
poisoning. 

There has been a marked divergence of 
opinion as to the etiology of the cyanosis. 
The formation of methemoglobin in the 
blood is in all probability an important fac- 

16. Gardinier: Chronic Acetanilid Poisoning a 
Perfectly Definite Symptom Complex, Boston 
M. and S. J. 165:199, 1911. 

17. Stengel and White: A Case of Acetanilid 
Poisoning- with Definite Blood Changes, U. of 
Penn. Med. Bulletin, 15:462, 1902-1903. 

19. Kracke: Relation of Drug Therapy to Neu- 
tropenic States, J.A.M.A. 111:1255, 1938. 



tor, although the observations of numerous 
investigators tend to minimize this element 
(20)^ (10)^ (21)^ (9)_ According to these and other 
writers, the cyanosis is due to the presence 
of dark colored derivatives of para-amino- 
phenol in the plasma and tissues, the para- 
aminophenol resulting from the decomposi- 
tion of acetanilid. The para-aminophenol is 
secreted in the urine, producing the dark, 
reddish brown color that is characteristic of 
all cases. 

Tolerance to the drug is developed in most 
instances and at times may become very pro- 
nounced. Enormous doses of acetanilid have 
been taken in some cases with little toxic 
effect. The severity of the drug addiction 
usually parallels the degree of tolerance. 
Withdrawal symptoms are apt to be quite 
severe, with exaggeration of the complaints 
for which the drug was originally taken. 

Two case reports of chronic poisoning 
with addiction will be presented: 

Case 1 : C. J., 47, a white male textile 
worker, was seen at my office in June 1936, 
with the chief complaint of severe frontal 
headache. He stated that the headache, 
which first appeared nine years previously 
had begun shortly after starting work on 
the night shift in a textile mill. During 
the first few years, he did not consult a 
physician but sought relief in various patent 
remedies. Five years previously he began 
taking "B. C. Headache Powders," and soon 
found that this was the only remedy which 
would give him relief. The headaches gradu- 
ally increased in severity and a proportion- 
ately larger number of powders was re- 
quired. At the time of his first visit, he 
was taking from 6 to 10 powders daily. 
Upon being questioned, he revealed further 
symptoms. He stated that for two or three 
years he had not been in good health. His 
appetite was poor, and there was some 
weight loss. He tired easily and had diffi- 
culty at times in continuing his work. Mod- 
erate exertion caused palpitation and short- 
ness of breath. He stated that he was 
bothered with a gaseous type of indigestion 
which he attributed to constipation. At in- 
tervals there were attacks of "up.set stomach" 
with vomiting and diarrhea. He believed 
that his vision was poor. 

20. Bachman: Cyanosis from Acetanilid, N. Y. 
Med. J. 65:708, 1897. 

21. Lundsteen: Chronic Acetanilid Poisoning, Ab- 
-stracts, J.A.M.A. 111:2534, 1938, 



146 



NORTH CAROLINA MEDICAL JOURNAL 



March, 1940 



The patient was of small stature and ap- 
peared rather weak. He seemed dull, apa- 
thetic and resentful. The outstanding fea- 
ture of the physical examination was the 
peculiar color of the skin. The patient was 
pale and anemic, but a bluish, cyanotic tinge 
was superimposed on this pallor. This cy- 
anosis was most evident at the lips, mucous 
membrane, and fingers. The nail beds were a 
pale, bluish-white color. The pulse was 
slightly accelerated, (80 per minute), and 
the blood pressure rather low (110/70). 
There were carious teeth, diseased tonsils 
and epigastric tenderness. The rest of the 
examination was essentially negative. The 
urine was dark amber, with a questionable 
trace of albumen. 

An eye consultation was advised, and the 
subsequent examination revealed some re- 
fractive error with eye strain. I believe this 
to be the original cause of the headaches. 

I next saw this patient about one year 
later, when I was called to his home by his 
wife, who told me that her husband had 
"lost his mind". She stated that he had been 
steadily increasing his consumption of B. C. 
powders, and had recently been taking large 
doses of brominyl and barbital in addition. 
On one recent occasion he had taken twenty- 
two B. C. powders within a four hour period, 
which represents approximately 88 grains of 
acetanilid and 264 grains of bromide. With 
the increase in drugs, the mental changes 
had become increasingly apparent. Because 
of the pronounced mental derangement and 
the impossibility of controlling the patient 
at home, he was sent to a nearby sanatorium 
for a few weeks. He was discharged, ap- 
parently relieved of his drug addiction. 

When questioned recently, he stated that 
his headaches quickly returned after his dis- 
charge from the sanatorium, and he was 
forced to go back to the B. C.'s for relief. 
He is now taking approximately 40 to 60 
grains of acetanilid daily. The cost of these 
powders amounts to $2.50 to $3.50 each 
week. 

Case 2: J.Y. S., 48, a white male textile 
worker, complained of persi.stent headache, 
nervousness, and intermittent cough extend- 
ing over a three year period, and general 
weakness. He also complained of various 
pains all over the body, most marked in the 
chest and back. Other symptoms were .short- 
ness of breath, and a gaseous type of indi- 



gestion. Recently he was having attacks of 
dizziness and "blind spells". Examination 
of the patient revealed an early Bronchiecta- 
sis with Vincent's organisms predominating 
in the sputum. The pulse was slightly fast, 
B. P. 180/110. There was slight cardiac en- 
largement and general tenderness through- 
out the abdomen. There was evidence of 
Vincent's infection of the gums. In this 
patient also, the striking finding was the 
marked pallor and cyanotic appearance of 
the skin and mucous membrane. There was 
a definite icteric tint to the sclera. 

The patient admitted that for the past 
eight years he had been taking large amounts 
of "B. C. Headache Powders" for the relief 
of chronic headache and nervousness. He 
had gradually increased the amount neces- 
sary for relief, so that at the present time 
he averages twelve to eighteen powders con- 
taining 48-72 grains of acetanilid daily. At 
times he has taken more. The cost of his 
powders usually represent the earnings of 
one day's work each week. He states that 
he finds it impossible to work without the 
powders and that he usuall.v has to take one 
or two during the night. His wife says that 
he has lost a great deal of time from his 
work since he began the B. C. habit, and in 
spite of repeated warnings, he continues with 
the addiction. 

Comment 

Acetanilid poisoning and drug addiction 
have constituted a problem to the medical 
profession since 1900. The indiscriminate 
use of acetanilid and the early introduction 
to the public of the various proprietary 
nostrums containing acetanilid led to many 
cases of poisoning. As early as 1906 Austin 
and Larrabee, in reporting two cases of 
acetanilid addiction from a preparation 
called "Nervease" state : "The lesson is that 
drugs of this dangerous character should not 
be dispensed except on a physician's pre- 
scription, and their sale should be as strictly 
guarded as is that of Strychnia or aconite." 
Following this and other publications ad- 
verse propaganda by the medical profession 
apparently produced a relative decrease in 
the number of cases of poisoning and addic- 
tion. However, within the last few years 
there has been a tremendous increase in the 
number of cases, due to the wholesale ad- 
vertising of patent medicines to the laity. 



March, liUO 



ACETANILID POISONING— McINTOSH 



147 



One cannot read a paper, listen to the radio, 
or drive along country roads without being 
impressed with the extensive advertising 
campaign. Such nostrums are sold without 
the slightest restrictions or warning con- 
cerning toxicity, excessive dosages, or habit 
formation. The various types of powders 
are dispensed in large quantities everywhere 
from grocery stores to filling stations. As 
a result of inquiries at one of the grocery 
stores in a mill village in my community, I 
found that this store alone sold over one 
gross of packages containing two powders 
each of a well known patent powder each 
week. The sale in another store in a dif- 
ferent mill village averaged a gross every 
three weeks. These are rather startling fig- 
ures when we realize that there are numer- 
ous other places dispensing the same powder 
in each community. Incidentally, the clerk 
in the first store mentioned the fact that 
practically all of the powders were sold each 
week to the same customers, numbering 
about twelve in all. 

The two headache powders most common- 
ly used in my district are known as "B. C." 
and "Stanback." A recent analysis of these 
powders by government chemist for the Food 
and Drug Administration (J. A. M. A., July 
23, 1938, Page 338) showed each powder of 
B.C. to contain approximately four grains of 
acetanilid, 6V» grains of salicylic acid, and 
12 grains of potassium bromide. The Stan- 
back powder contained about 2 grains of 
acetanilid, 6 grains of acetysalicylic acid, 
and 12 grains of potassium bromide. Bromo- 
Seltzer, which has long been a favorite, 
contains approximately 3 to 31/2 grains of 
acetanilid to the dose. 

Chronic acetanilid poisoning with addic- 
tion is found among all classes of people, but 
is a major problem in the industrial and 
rural communities. It is very prevalent in 
the textile districts of the South. Payne"" 
states that each week several cases of 
chronic poisoning by "pain killer" remedies 
are seen in the out-patient department of 
Duke Hospital. Every physician with whom 
I have discussed the problem has seen va- 
rious instances of the social, economic, and 
physical damage produced by acetanilid ad- 
diction. 

The family physician and general prac- 
titioner is the one who is most frequently 
called upon to treat these unfortunate vic- 



tims, and it is this group of the medical pro- 
fession which should be vitally interested in 
working out a solution to this ever-increas- 
ing problem. It represents a challenge which 
we should meet at once. 

I can see only one proper solution to the 
problem arising from the indiscriminate 
use of such toxic and dangerous drugs as 
acetanilid. Dispensing of the drug should 
be limited to the medical profession, and the 
prescriptions should be non-refillable, as with 
the narcotics. Until the drug is placed on 
this basis, it is our duty to acquaint the pub- 
lic by every means possible with the dangers 
and habit-forming possibilities of nostrums 
containing acetanilid. 

Discussion 

DR. T. W. BAKER (Charlotte): I want to con- 
gratulate Dr. Mcintosh on a very splendid paper 
indeed. 

There is one little point I would like to emphasize 
here: In many of these cases in which we are 
seeing poisonings from the patented headache reme- 
dies, the trouble is due as much to bromide intoxi- 
cation as it is to acetanilid, I think. We are find- 
ing now far more frequently than we used to be- 
lieve that a lot of our psychoses of a temporary 
nature are really due to bromides, and several recent 
surveys at mental sanatoria have revealed the fact 
that a number of patients are there because of 
a bromide intoxication. If we take a blood bromide 
on these patients we find it up above the level of 
IBO milligrams per 100 cc. of blood, which is usually 
a psychotic level. If we eliminate patent acetanilid 
bromide preparations, and give these patients so- 
dium chloride intravenously and by mouth, we will 
find that many of our severe psychoses of a tem- 
porary nature will clear up within about a week's 
time. 



The Interpretation of Laboratory Findings. — A 

basal metabolism which is reported as 15 per cent 
above normal may or may not be significant, and 
an electrocardiogram showing a prolonged conduc- 
tion time may be due to one of several factors, but 
in either case the physician should not be forced to 
depend for the interpretation on the man who does 
the laboratory work and who presumably has a 
less intimate knowledge of the clinical condition of 
the patient. The clinician himself should be able 
to appraise the laboratory findings if the patient is 
to derive the greatest benefit. — Francis W. Peabody: 
Doctor and Patient, New York, The Macmillan Co., 
1939. 



Clinicians Needed More Than Technicians. — In 

spite of the extraordinary influence which the labora- 
tory has had on the development of medical science 
there is as yet no cause for the physician to feel 
that he cannot keep up with the requirements of 
the best modern practice. All of the more impor- 
tant elements are easily within his grasp. The 
need in clinical medicine continues to be, not for 
men trained in many laboratory methods, but for 
men well grounded in a few methods — not for bet- 
ter technicians, but for better clinicians. — Francis 
W. Peabody: Doctor and Patient, New York, The 
Macmillan Co., 1939. 



148 



NORTH CAROLINA MEDICAL JOURNAL. 



March, 1940 



THE MANAGEMENT OF OLD CON- 
TRACTURES OF THE HAND RESULT- 
ING FROM THIRD DEGREE BURNS 

Randolph Jones, Jr., M.D. 

Contractures of the hand and digits as a 
result of burns are common, and these de- 
formities often may be corrected, with sub- 
sequent improvement in the function of the 
hand, by suitable operative measures. Sup- 
plementary physiotherapy directed toward 
early restoration of function is an invaluable 
adjunct to surgical treatment. Each patient 
presents an individual problem. It is impor- 
tant to estimate the depth of the .scar, its 
attachment to the deeper structures of the 
hand, and possible distortion of them, before 
deciding on the method of repair to be used 
in the particular case. Although the deform- 
ity may have been present for a decade or 
more and may have existed during the 
growth period of the individual, much can 
be done to improve the usefulness and ap- 
pearance of the member. Davis"- =', Blair 
and Brown"', and others who have obtained 
excellent results in treating these deformi- 
ties have enumerated the principles used in 
their correction. 

The cases with contractures of the hand 
presented herein fall readily into three 
groups. In the first are those patients hav- 
ing cicatrices on the palmar surfaces of the 
digits, which in some instances extend down 
on the palm it.self and cause web-like flexion 
contractures of the fingers. These webs fre- 
quently may be released by the interposition 
of flaps formed by incisions made at an angle 
to an incision splitting the contracture itself 
along its leading edge, a procedure advocated 
by Blorestin in 1914. 

The scar in the second group of cases is 
broad, but is unattached to the deeper struc- 
tures of the hand, and is best treated by 
excision of the cicatrix with the underlying 
fascia, leaving a protective layer of fat over 
the nerves, muscles, and tendons beneath. 
When the palm or the palmar surface of the 
finger is involved, the defect created by ex- 

From the Dcp.artiiu'nl of Surgerj-. Duke I'niversity Schnol of 
>tc(Ucine. Durham. N. C. Read before the Section on Sursery. 
Medical Society of the State of North Carolinit, Bermuda 
Cruise. May 13, 1930. 

1. Davis, John S.: The Use of Free Grafts of Wluile Tlilck- 
ness Skin for the Relief of Contractures, Surg., Gynec, 
and Oljst. 25:1. IH17. 

2. Davis, John S. : Plastic Surirery. Its Principles and 
Practice. Philadelphia. P. Biakiston's Sons and Co., I91fi. 

8. Blair, v. P., and Brown. J. B. : The L'se and L'ses of 
Large Split Skin Grafts of Intermediate Thickness, Surg.. 
Gynec, and Obst, 49:82, 1929. 



cision of the constricting scar may be cov- 
ered with a full thickness or Wolfe Krause 
graft. A thick split graft may be used if 
the dorsum of the hand or the finger is to be 
covered with skin. 

A representative contracture of the third 
type is caused by a scar which extends from 
the skin to the muscles, ligaments, tendons, 
or joints of the hand. This fibrous tissue 
should be stretched as much as possible by 
the intensive use of physiotherapy before 
operation. A full range of motion of the 
hand and fingers may follow excision of the 
cicatrices in many of these cases; but unless 
an adequate fat pad is interposed between 
the skin and the deeper structures, the con- 
stricting scar will in time re-form and the 
result will be unsatisfactory. Elastic trac- 
tion and other physiotherapeutic measures 




Fig. 1. Contractures ot the thumb and small finger 
resulting from a burn received 2'/2 years previously. 
These were released by the interposition of flaps 
formed by incisions made at an angle to the long 
axis of the web after the latter had been incised. 
The lower photographs were taken 5'/2 months 
after operation. 



March, 1940 



CONTRACTURES OF HAND— JONES 



149 



are of great assistance in obtaining early 
return of function after operation. 

The first group of cases mentioned above 
is exemplified by the patient's hand shown 
in Figure 1. This white girl, seven years 
of age, burned her right hand severely when 
she fell in an open fire two and one-half 
years before. Although the skin healed satis- 
factorily, the scars on the palmar aspects of 
the thumb and small finger had caused the 
fiexion contractures visible in the photo- 
graphs taken when she was admitted to the 
hospital. These were released by the inter- 
position of flaps formed by suitable incisions 
on the sides of the webs. A satisfactory 
functional and cosmetic result was obtained. 

Examples of the second group of broad 
contracted scars are the patient's hands 
shown in Figure 2. The left hand of this 
eleven year old boy had been burned ten 
years before when he fell against a hot stove. 
Subsequent scarring and contracture had 




Fig. II. The palmar scar shown above followed a 
burn received when the patient fell against a hot 
stove 9 years before. The scar was excised, allow- 
ing the pa!m to return to approximately normal 
size. The full thickness graft used to cover the 
defect following excision of the scar has become a 
satisfactory palmar skin. 



prevented full extension of the fingers. The 
scar, which extended down to the palmar 
fascia, was completely removed, leaving a 
pad of fat overlying the deeper structures of 
the palm, upon which the full thickness graft 
took with an excellent functional result. 
Brown<^> has shown that when the scar is 
on the dorsum of the hand, durable skin may 
be obtained by using a thick split graft in 
this location. 

A contracture of the third group listed 
above is shown in Figure 3. At times the 
puckering of the scar, the limitation of mo- 
tion present, and the duration of the con- 
tractures will produce a definite impression 
that the deeper structures are adherent to 
the skin cicatrix. When these findings are 
present, preparations can be made to place 
the hand beneath an abdominal flap of skin 
and sub-cutaneous fat, or to raise a tube flap 
if this is thought best. At other times, how- 
ever, the operator may plan to cover the de- 
fect left by excision of a palmar contracture 
with a full thickness graft, but may at op- 
eration find that the scar is deeper than first 
estimated and that the flexor tendons and 
the carpal ligaments are exposed after the 
removal of the cicatrix. 

A situation of this kind was encountered 
at operation on this patient's hand shown 
in Figure 3. In order to provide the neces- 
sary palmar skin and to cover the flexor 
tendons and the transverse carpal ligament 
with fat, the defect was filled with a pedicle 
flap raised from the abdominal wall. The 
area from which the flap had been taken was 
covered at the same time with a Thiersch 
graft. By this means the cushion of fat 
necessary to maintain normal tendon func- 
tion was obtained, and a deformity which 
had been present for fourteen years was ef- 
fectively corrected. 

A pedicle or tube flap with its subcuta- 
neous fat may prove the only means of re- 
leasing a contracture which other measures 
have failed to relieve. An illustration of this 
was seen in the treatment of the deformed 
hand shown in Figure 4. Two operations 
elsewhere had failed to release the contracted 
fingers, and although some improvement fol- 
lowed the interposition of angle flaps along 
the contracture combined with the applica- 
tion of palmar full thickness grafts, it was 
necessary eventually to transplant a tube 
flap to the palm and fingers before a full 
range of motion could be obtained. 



150 



NORTH CAROLIN'A MEDICAL JOURNAL 



March. 1940 




Fip. IIL A. Contractures of the thumb and small 
finger of 14 years' duration. B. The scar tissue 
has been excised and the palmar defect covered with 
a pedicle flap which is still attached to the abdomi- 

About the periphery of extensive scars 
there are often one or more band or web-like 
contractures. Release of these by the inter- 
position of angle flaps usually makes the cor- 
rection of the main scarred area easier, and 
results in more normal tension after the deep 
cicatrix has been excised. The web at the 
wrist shown in Figure 5 was released in this 
manner, and the palm reconstructed by a 
tube flap from the abdominal wall. 

The third type of contracture may be as- 
sociated with damaged tendons or nerves 
and with some bone deformity. Kanavel,<" 
Bunnell,'^' Mason,"" Meyer,<"' and Koch'" 
have stated the principles to be followed in 

4. Kan.ivel. .\llen B.: Infections of the Hand. ed. 6. Phila 
detphia, Le,a and Febiger. 1983. 

5. Bunnell. Sterling: The Surger>' of Tendons, in l.ewis: 
Practice of Surgery. Hagerstown, Md., W. F. Prior Co.. 
Inc.. 193U. vol. 6. 

«. Mason. M. I,.: Immediate and Delayed Tendon Repair. 
Surs.. Oynec.. and Obst. 62:149. 1936. 

7. Meyer. L.. Ransohoff. N. S.: Contribution to Physiological 
Method of Repair of Damaged Finger Tendons; Prelimi- 
nary Report on Reconstruction of Destroyed Tendon 
Sheath. Am. J. Surg. 31:56. 1936. 

». Koch. S. L. and Mason. M. L.: Purposeful Splinting 
Following Injuries of the Hand. Surg., Gynec., and Obst.. 
68:1, 1939. 



nal wall. C. and D. Hand, shortly after division of 

the abdominal pedicle flap. E. Hand after the 

transverse scar across the palm had been lengthened. 

F. Splint to be worn at night for six months. 

the management of these complicated prob- 
lems, and a discussion of this type of case is 
beyond the scope of this paper. Neverthe- 
less, too much emphasis cannot be placed on 
preventing skin contractures following third 
degree burns by early restoration of the skin 
loss and early resumption of function. When 
the hand is involved, the "thick split" graft 
of Blair and Brown"* answers this need bet- 
ter than any means yet devised. 

In the management of old contractures 
proper physiotherapy and splinting, with the 
use of elastic traction in cases of long stand- 
ing, are of greatest assistance in obtaining 
an adequate return of function. In the ma- 
jority of the cases presented herein it was 
found advisable for a splint to be worn at 
night for six months, maintaining and in- 
creasing the reduction of the contracture 
secured at operation. Gentle massage of a 
bland ointment into the scars for two to 
three months after operation increases their 
later pliability. 



March, 1940 



CONTRACTURES OP HAND— JONES 



151 





Fig. V. A contracture of the palm and wrist of 11 
years' duration. This was released by transplan- 
tation of a tube flap to the palm and the interposi- 
tion of ilaps of skin along the web. The lower 
photograph shows the hand 3 months after correc- 
tion of the deformity. 



Fig. IV. A. A scar of the palm and the palmar 
surfaces of the fingers 5 years after a burn. B. 
Partial relaxation has been obtained bv the inter- 
position of skin flaps and the transplantation of 
several small full thickness grafts. C. Transplan- 
tation of a tube flap from the abdominal wall to 
the palm, after the palmar scars had been excised. 
D. Hand shortly after and (E.) two years after 
transplantation of tube flap. 

Abstract of Discussion 

DR. J. L. WINSTEAD (Greenville): Dr. Jones 
has told you how to treat contractures of the hand. 
I shall attempt to tell you how to prevent them. 

Severe and untreated acute infections in the hand 
result in contractures with deformity and disability. 
Kanaval has shown that infection spreads along the 
blood vessels and nerves. The resulting scar tissue 
compresses the blood vessels, nerves and lymphatics, 
causing trophic changes. Joints are ankylosed, 
muscles contracted, and tendons destroyed or dis- 
abled by adhesions. 

The pathological picture is one of destruction of 
blood and nerve supply with massive connective- 
tissue contraction about structures that have a most 
delicate function. Much can be done by prophylac- 
tic measures and active treatment to preserve and 
restore function. We should constantly bear in mind 
that we are not only attempting to overcome infec- 
tion but also to preserve function. Most hand in- 
fections can be prevented by the administration of 
proper treatment immediately to injured hands. 
Sometimes a most serious infection will follow a 
slight injury because the injury received no treat- 
ment, or inadequate treatment. The staphylococcus 
is the organism in most hand infections. The strep- 
tococcus comes next in frequency, and usually causes 
a very rapid, severe inflammation with a marked 
tendency to spread to various spaces in the hand 
and to the forearm. The anemic, undernourished, 
or mn-down individual is far more prone to infec- 
tions. 

When infection does occur, hot moist dressings 
continuously applied for twenty-four to forty-eight 
hours with complete rest will often abort it. 

Hand infections are serious from their inception 
and demand proper diagnosis of the type and nature 
of the infection. 



152 



NORTH CAROUNA MEDICAL JOURNAL 



March. 1940 



When pus appears, its exact location should be 
determined. The abscess should be incised properly 
in order to establish adequate drainage and yet not 
spread the infection to other spaces. In severe in- 
fections of the hand where stiffening and loss of 
function is impending it is of great importance to 
splint the hand in the "position of function" — that 
is, foity-flve degrees dorsal flexion of the wrist. 
The phalanges at the metacarpo-phalangeal and 
phalangeal joints should be flexed to the same angle, 
and, most important, the thumb should be abducted 
from the palm, adducted toward the ulnar side of 
the hand, and rotated so that the flexor surface of 
the thumb is opposite the flexor surface of the index 
finger. This position should be maintained through- 
out the treatment except when the hand is under- 
going physiotherapy. 

DR. PARKER C. HARDIN (Monroe): I noted 
that Dr. Jones based his discussion on the fact 
that most of these cases follow burns — old neglected 
burns. For some time I have been interested in 
the question of the healing of burns in relation to 
the necessity of skin grafting, and have been trying 
to find out just exactly the amount of skin grafting 
necessary following the various types of therapy in 
major bums. We can, by studying the results in 
the different methods, find out those in which most 
skin grafting is required. We can look forward to 
the time when we can eventually choose for various 
burns the method which will lead to the least amount 
of scarring. 

With contractures resulting from a bum it is wise 
to resort to skin grafting as soon as the wound is 
in condition to do so. 

DR. RANDOLPH JONES, JR. (Durham): I en- 
dorse most heartily Dr. Winstead's emphasis upon 
the necessity of treating any infection that is pres- 
ent in the hand. Infection that is present even in 
burns should be treated intensely. 

If any method is used in which coagulum forms 
over a third degree burn much is to be gained by 
moving that coagulum as early as separation begins. 



Urinalysis. — The methods for the examination of 
the urine are taught much as they were two decades 
and more ago. Certain tests, such as urea deter- 
minations, have been discarded and others are re- 
garded as having a different significance, but the 
records still show the color, specific gravity, re- 
action, albumin and sugar content, and the micro- 
scopic examination of the sediment. These simple 
observations, correctly used and interpreted, are 
practically all that is necessary in cases of nephritis. 
— Francis W. Peabody: Doctor and Patient, New 
York, The Macmilan Co., 1939. 



Laboratory Procedures. — What is really needed 
in the application of laboratory methods to the 
practice of medicine is not a knowledge of more 
technical procedures, but a much more exact knowl- 
edge of a few. If every physician was so much at 
home with the technique of the simpler tests that 
it was quicker for him to apply them than to won- 
der whether they were worth while applying, and 
if he understood how to interpret these tests and 
gain the maximum information from them, the 
problem of the relation of the physician to the 
laboratory would be largely settled. — Francis W. 
Peabody: Doctor and Patient, New York, The Mac- 
millan Co., 1939. 



DIAGNOSIS AND TREATMENT OF 
NEUROSYPHILIS 

J. P. Davis, M. D. 

Winston-Salem 

The proper management of patients with 
syphilis in private practice depends funda- 
mentally on an early and accurate diagnosis. 
Despite the facts which have been derived 
from valuable experience by such men as 
Stokes, Grinker, Nonne and others, the early 
diagnosis of neurosyphilis very often is over- 
looked. Failure to diagnose neurosyphilis, 
when present in its early or incipient stage, 
may be as serious in its consequences as not 
recognizing cancer in its treatable stage. So 
much of the responsibility for the prevention 
of neurosyphilis rests upon the practicing 
physician that its diagnosis and treatment 
deserve more widespread discussion. 

The incidence of neurosyphilis has been 
set at varying percentages. Stokes"' esti- 
mates that 10 per cent of a general hospital 
population is syphilitic, of which between 60 
and 70 per cent show evidence of neuro- 
syphilis on complete examination. The pro- 
portion of 6 to 7 per cent of a general hos- 
pital population having syphilis of the cen- 
tral nervous system may appear high to 
many of us ; but may the answer not be that 
we do not always recognize it? 

A fact which is not generally appreciated 
by many of us who do general practice is 
that syphilis invades the nervous system long 
before symptoms appear. Stokes and Mc- 
Farland'-' reported the results of routine 
spinal fluid studies on 114 early secondary 
untreated cases. Thirty -seven per cent 
showed abnormal spinal fluids, as indicated 
by a marked increase in cell count or a posi- 
tive Wasserman reaction. Only 16 per cent 
revealed any symptoms of neurosyphilis, and 
none showed abnormal neurological signs. 
In patients who had received treatment the 
percentage of abnormal spinal fluid findings 
was lower. In a florid syphilitic infection 
the earlier the spinal fluid is examined, and 
the less treated the case, the higher the find- 
ings of meningeal involvement. About one- 
fourth of all early syphilis may be expected 



Read before the Section on the Practice of .Medicine. Medical 
Society of the State of North Carolina. Bermuda Cruise, May 
13. 1989. 

1. Stokes. J. H.: Modem ainlenl SypWloloo-. Philadelphia. 

W. B. Saunders Co.. 1998. p. 9o:. 
i. Ibid. p. 9!!. 



Maic-li, 1940 



NEUROSYPHILIS— DAVIS 



153 



to have neurosyphilis as an integral part of 
the clinical picture. 

The practitioner is usually unable to de- 
tect any abnormal symptoms and signs, be- 
cause most patients are entirely asympto- 
matic in the early stages of involvement. 
For this reason pathologic changes can only 
be detected by spinal fluid examination. 
Early changes in the nervous system are ir- 
ritative, actually a meningeal reaction, and 
are thus devoid of marked signs or symp- 
toms. The later changes which we detect 
when the pupils are fixed, the gait is affected, 
or the mental reactions are abnormal, repre- 
sent a permanent damage or scarring of 
nervous tissues by the spirochetes. 

The spinal fluid in early cases of menin- 
geal involvement passes through a rather 
typical series of changes. The first warning 
of any trouble present is an increase in cell 
count and globulin content, representing 
purely a meningeal reaction. Later, as par- 
enchymatous changes occur, serological re- 
actions become positive. The spinal fluid 
serology is not likely to become positive until 
the infection is well established, which may 
be as long as one or two years after begin- 
ning invasion. The colloidal gold reaction 
appears only when the process is fully de- 
veloped, representing a .severe neurosyphilis. 

The diagnosis of neuro.syphilis in an early 
stage, aside from the study of the spinal 
fluid, depends more upon subjective .symp- 
toms than upon physical signs. The symp- 
toms are likely to be vague and easily mis- 
taken for one of many benign conditions. 
Generally, they are the .symptoms of a mild 
meningeal irritation or an encephalitic in- 
volvement. 

Headache is an almost constant early com- 
plaint. A persistent headache in a known 
syphilitic should always prompt a lumbar 
puncture and, when encountered in a new 
patient, should lead to blood and spinal fluid 
studies. Other early symptoms which .should 
create suspicion and demand a spinal fluid 
examination are vertigo, nausea, vomiting, 
failing vision, diploplia, tinnitus, neuras- 
thenia and mental confusion. 

While we are largely dependent upon 
symptomatology and spinal fluid changes for 
the diagnosis of early syphilis of the nervous 
system, definite neurological and mental 
signs usually are at hand to help in the de- 
tection of late neurosyphilis, owing to per- 
manent and often irreversible pathologic 



changes in the central nervous tissue. Path- 
ologists have, for the sake of convenience, 
classified neurosyphilis according to the lo- 
cation of its pathologic process. First, men- 
ingeal, which designates the pathology of 
early neurosyphilis, both with and without 
symptoms. Second, cerebro-vascular, as rep- 
resented clinically by aphasia and paralyses. 
Third, parenchymatous, characterized by de- 
struction of nerve cells of the cerebral cortex 
and posterior spinal ganglia, producing the 
clinical pictures of paresis or tabes-dorsalis. 
The fourth classification represents variable 
combinations of the above three — for in- 
stance, meningo-vascular or meningo-vascu- 
lar-pai-enchymatous — which are clinically 
called cerebro-spinal syphilis. 

The symptomatology of neurosyphilis does 
not always correspond with this pathologi- 
cal classification, because many important 
symptoms may be common to more than one 
type. Thei'efore, for clarity, it is best to dis- 
cuss the symptoms of neurosyphilis in gen- 
eral. 

Headache, as in early neurosyphilis, is 
likewise common in late neurosyphilis. It is 
usually boring and severe, often worse at 
nights, either generalized or localized deep 
in the eyes, and at times associated with 
dizziness and vomiting. 

Convulsive seizures are common in cere- 
bro-spinal and paretic syphilis, and rarely 
may appear within a few months after in- 
fection in precocious cases. They may range 
from generalized convulsions and Jacksonian 
.seizures to petit mal attacks with preserva- 
tion of consciousness. No epilepsy should be 
branded "essential" without a spinal fluid 
study. 

Personality changes and neurasthenic 
.symptoms should always be considered as 
possible prodromes of cerebi'al .syphilis. The 
distinction from true neurasthenia may be 
hard to draw and, considering the large num- 
ber of neurasthenics in private practice, it 
would be unwise to perfoi-m spinal punctures 
on them all. Yet, because of the seriousness 
of allowing early paresis to progress un- 
treated, every patient with a nervous break- 
down in middle life should have a careful 
history, thorough physical and neurological 
examination and blood serology test. Often 
neurasthenic syndromes are labeled as "over- 
work," "nervous breakdown", or simply as 
a "neurosis", whereas a complete physical 
examination may reveal a sluggish pupil, an 



154 



NORTH CAROLINA MEDICAL JOURNAL 



March, 1940 



optic neuritis or a positive blood serology. 
After a thorough study of the neurasthenic 
has been made and no economic, social or 
spiritual cause is uncovered, or if the history 
or examination suggests syphilis, a spinal 
fluid examination is then indicated. 

Personality changes, or what has been 
termed a "conduct slump", may precede by 
months or years the ultimate dementia or 
paresis. Egotism, expansiveness, careless- 
ness of appearance, speculative spending and 
change from conservatism to radicalism are 
characteristic of the paretic but may be 
overlooked due to their insidious appearance. 
Sexual laxity, persecutory ideas, depression, 
exaltation, or violence may make paresis 
simulate almost any major psychosis. Speech 
disorders, especially a slurring of words or 
transient aphasia, often are the first recog- 
nized signs of paresis. 

Sharp, stabbing, lightning-like pains are 
a common symptom in neurosyphilis. They 
may follow the spinal nerves or may be spot- 
like, hitting in succession several parts of 
the body. "Rheumatism" is too often the 
diagnosis which is made to cover this symp- 
tom. Fleeting sensations of burning, ting- 
ling and numbness may shift from place to 
place. Transient parasthesias are always 
suggestive of neuro-syphilis. One of the first 
warnings of tabetic neurosyphilis is loss of 
bladder control. Owing to impairment of in- 
nervation, the bladder musculature becomes 
atonic and dilated, resulting in retention, 
overflow, and "dribbling". Oftentimes these 
symptoms are wrongly blamed on an en- 
larged prostate. Disappearance of libido oc- 
curs in about 30 per cent of cases of neuro- 
syphilis. 

Syphilitic meningitis, through damage to 
the cranial nerves, gives rise to eye symp- 
toms and signs. Ptosis of one lid, diplopia 
and strabismus are not uncommon findings. 
Failing vision often results from primary 
optic atrophy, which should be determined 
by ophthalmoscopic and perimetric examina- 
tions. Is the Argyle-Robertson pupil abso- 
lutely diagnostic of neurosyphilis? Nonne 
concludes that a pupil which is fixed to light 
but reacts to accommodation points to syphi- 
lis in nearly every case. Though there may 
rarely be other causes than neurcsyphilis, 
finding of such a i)upil absolutely indicates 
serologic and spinal fluid studies. 

In the diagnosis of early neurosyphilis 
there are certain objective signs which are 



valuable. Sensory changes, especially anal- 
gesia to pin-prick, impairment of vibratory 
sense, and loss of the sense of motion and 
position are often the earliest warnings of 
sen.sory root involvement. As the sensory 
roots become more injured the advanced 
tabetic is produced, with a positive Romberg 
test, slap-foot gait, and absent tendon re- 
flexes. Hemiparesis, spastic gait, ankle 
clonus, positive Babinski, and hyper-active 
reflexes may indicate a syphilitic process of 
the brain or spinal cord. 

Just how reliable are the blood and spinal 
fluid serological reactions in the diagnosis of 
neurosyphilis? The blood serology is esti- 
mated by various syphilologists as being posi- 
tive in only 50 to 60 per cent of tabetics ; 
but in paresis it is usually accepted as posi- 
tive in 90 to 100 per cent. Although a posi- 
tive spinal fluid serology is to be expected in 
100 per cent of paretics, negative results are 
occasionally found in cases of meningeal, 
va.scular and gummatous neurosyphilis. 

The colloidal tests are not as valuable for 
diagnosis as they are for prognosis. A first 
zone, or so-called "paretic curve", is not 
pathognomonic of paresis. The diagnosis of 
neurosyphilis depends, therefore, not on any 
one single finding, but must be made from 
the history, clinical findings, blood and spinal 
fluid serology, colloidal test and cell count. 

Treatment 

The treatment of neurosyphilis is still in 
a state of change and development. Syphilo- 
logists who report on the results of treatment 
of large groups of clinic patients show vary- 
ing, and even contradictory results. Not all 
workers agree on the relative values of the 
various forms of therapy in common use. It 
is, therefore, impossible to present all the 
forms of treatment which have been and 
are being employed in treating the various 
phases of the disease. In appraising the re- 
sults of treatment of syphilis of the nervous 
system, it is well to use the accepted patho- 
logical classification. 

First, in usymptowatic neurosyphili.i the 
results of treatment depend on the -severity 
of the spinal fluid reaction. The Cooperative 
Clinical Group'-" reports a reversal of the 
milder types of spinal fluids to negative in 
84 per cent of cases, while in those cases 
with a first zone curve only 45 per cent were 
reverted to negative, remaining negative for 
ten years or more. Routine treatment con- 



March, 1U40 



NEUROSYPHILIS— DAVIS 



155 



sisted of intensive use of arsphenamine and 
bismuth or mercury. In those cases which 
were resistant to routine therapy, trypars- 
amide, therapeutic malaria, or intraspinal 
therapy was used. Each of these three addi- 
tional methods resulted in a reversal of 
spinal fluids in from 25 to 75 per cent of 
cases resistant to chemotherapy. 

Secondly, in earlij meningeal neitrosyphi- 
Us, Stokes and Shaffer"* urge intensive 
treatment with arsphenamine and a heavy 
metal, with longer courses of the former and 
no rest periods. They obtained good results 
clinically and serologically in 91 per cent of 
cases. O'Leary*^' treats those of this group 
who have paretic curves by supplementing 
the chemotherapy with malarial therapy. 

Thirdly, in vascular neurosyphilis results 
of treatment are discouraging. Stokes and 
Shaffer obtained good results in only 38 per 
cent of treated cases. The prolonged use of 
neoarsphenamine, heavy metals and iodides 
is recommended. Tryparsamide has pro- 
duced favorable results, though it is stated 
that malarial therapy is hazardous for these 
patients. 

Fourth, late meningo-vascular syphilis re- 
sponds comparatively well to therapy, as 
shown by Moore<"> who treated 88 cases at 
Johns Hopkins Hospital. Good results, clin- 
ically and serologically were obtained in 62 
per cent of cases. Tryparsamide, heavy 
metals and iodides are used in this type of 
the disease. Malarial therapy is of consider- 
able use in those cases resistant to chemo- 
therapy, and intra-spinal treatment was at 
one time being widely used. 

Fifth, the results of treatment of tabes 
dorsalis are difficult to appraise, because the 
symptoms are so multiform, and clinical im- 
provement does not parallel serologic im- 
provement. 0'Leary<" reports a series of 
630 cases of tabes. Chemotherapy, consist- 
ing of tryparsamide, bismuth and iodides, 
produced serologic reversals in 64 per cent 
and excellent clinical results in only 26 per 

3. 0'Le,iry. P. A.: Cole, H. N.: Moore, J. E.; Stokes. J. H.; 
Wile, U. J.; Parran, Thomas; Vonderlehr, R. A.; Usil- 
ton. LitJa J.; Cooperative Clinical Studies In the Treat- 
ment of Syphilis: Asymptomatic Neurosyphilis, Yen. Dis. 
Inform. ls:15 (March) 1937. 

I. .Stokes, J. H.. and .Schaffer. L. W.: Syphilis, J. A. M. A., 
S3: 1826, 1024; ibid., 85: 1271, 1025. 

:>. fl'Leary. P. A., and Welsh. A. L. : The Treatment of 
Veurosyphilis with Malaria, Observations on 084 Ca.se8 
in the Last Nine Years, J. A. M. A. 101: 408-501 (Aug. 
12) 1983. 

n. Moore. J. E. : The Modern Treatment of Syphilis, Balti- 
more, C. C. Thomas. 1933. 

7. O'Leary, P. A.: Present Dav Status of the Treatment 
of Neurosyphilis, J. A. M. A. 109: 1163-1166 (Oct. 9) 
1937. 



cent. Malarial therapy arrested clinically 26 
per cent of those cases in which routine 
treatment had failed, especially in cases of 
gastric crises, lightning pains and optic 
atrophy. Fordyce*"' reported excellent re- 
sults in 50 per cent of tabetics treated by 
the Swift-Ellis intraspinal method. 

Sixth, paresis shows little response to ar- 
sphenamine, bismuth, or mercury when u.sed 
alone. Moore"" obtained good clinical re- 
sults in 57 per cent of early paresis treated 
by tryparsamide, though only 28 per cent 
showed a good serological result. Among the 
more advanced institutional cases malarial 
therapy, followed by tryparsamide courses, 
causes complete remissions in about 35 per 
cent of cases and partial remission in about 
30 per cent. Wagner von Jauregg""' states 
that if only early cases of paresis are treated, 
malaria will give 100 per cent good results. 
Malarial therapy is undoubtedly of more 
value in cases in which there are no clinical 
signs of paresis, but in which a paretic 
spinal fluid persists in spite of intensive 
chemotherapy. Malarial therapy can, there- 
fore, be regarded as of great value in the 
prevention of clinical paresis. The produc- 
tion of febrile reactions by means of typhoid 
vaccines is useful. 

A few words regarding the action of try- 
parsamide are in order. This drug has been 
shown not to be spirillicidal, therefore hav- 
ing no field of use in early syphilis. Its exact 
action is not knowm; it is thought to stimu- 
late the immunity and resistance factors of 
the body. Stokes"" thinks it penetrates 
nerve tissue. Tryparsamide is valuable in 
the treatment of paresis, tabes dorsalis, 
meningeal neurosyphilis and meningo-vascu- 
lar neurosyphilis. It has special merit in 
the treatment of late neurosyphilis follow- 
ing or accompanying malarial therapy. It is 
now believed that, in- order to accomplish as 
much serologic as clinical improvement, mer- 
cury or bismuth, iodides, or even arsphena- 
mine, should be given also. The average dose 
of tryparsamide is about 3 Gm. in 10 cc. of 
sterile, distilled water, given at weekly in- 
tervals for eight to sixteen weeks, followed 
by a rest period of four to six weeks. Many 

s. Fordyce. J. A.: Syphilis. Brit. Jour. Dermat., 38: 17, 1024. 
9. Moore. J. E. : The Modern Treatment of Syphilis. Balti- 
more, C. C. Thomas. 193:J. 
in. Waffner von Jauregg. Julius: Ueber die Einwirkuiif; der 
Ma'ari.T auf die progressive Paralyse. Psychiat-neuroe. 
Wchnschr. 20: 132-134 (Aug. 31) 191S. 
11. Stokes. J. H. : Modern Clinical Syphilology, Philadelphia, 
W. B. Saunders Co., 1928, p. 131. 



156 



NORTH CAROLINA MEDICAL JOURNAL 



March, 1940 



such courses may be necessary. During try- 
parsamide therapy, any subjective ocular 
symptoms should prompt careful study of 
the visual fields. 

How long should the treatment of neuro- 
syphilis be continued? Some specialists at- 
tempt to treat their patients for one year 
after the blood and spinal fluid have become 
and remained completely negative. But, may 
not this attitude at times overlook the wel- 
fare of the patient in an attempt to combat 
the disease? The primary aim of treatment 
in neurosyphilis is to restore the patient to 
a state of physical and mental well-being, 
and to maintain this state as permanently as 
possible. Ordinarily, continuation of treat- 
ment for a reasonable time after the patient 
is clinically well, in order to keep the spinal 
fluid negative is wise practice. However, it 
is not within the aim of treatment to reverse 
a spinal fluid serology at the expense of the 
rest of the man. The undoubted answer is 
that careful individualization of each patient 
should be observed. His age, life expectancy, 
his work, his desires are as much a part of 
the handling of his individual case as are 
his symptoms or his positive spinal fluid 
serology'. 

From the above principles of diagnosis, 
methods of therapy, and results of treatment 
we may conclude the following: The earlier 
neurosyphilis is diagnosed and adequately 
treated, the more favorable will be the out- 
look for the patient. 



STPHi,.iS DElTHS IH 23COUHTIES Or MMTH CMOLIIU OUHmfi l»Sa 



A PRELIMINARY REPORT OF AN 

ANALYSIS OF THE DEATHS AMONG 

INDIVIDUALS WITH SYPHILIS 

IN NORTH CAROLINA 

DURING 1938 

G. M. Leiby, M.D., Dr.P.H., Consultant, 
Venereal Disease Control 

North Carolina State Board of Health 

The determination of the actual mortality 
rate for syphilis is practically impossible 
from data available on death certificates. 
This in a large measure is due to the protean 
nature of the disease, which causes it to 
present such varied clinical pictures that it 
is able to masquerade as many other diseases. 
Even when syphilis is recognized its actual 




Kcml before tlit Second General Session of the Medical Society 
of llie State of North Carolina, Bermuda Cruise, May IS. 1930. 



Fig. 1. Shaded areas represent health jurisdictions 

cooperating in study. Morbidity rates among syphi- 

litics per 100.000 of general population are indicated 

for each area studied. 

relationship to death may remain undis- 
covered. For example, the report of the 
Register-General of Great Britain in 1915 
placed syphilis as the tenth among killing 
infections; however. Osier upon analyzing 
the report found that syphilis actually ranked 
fir.it. His deduction was reached by esti- 
mating 18.4 per cent of all central nervous 
system deaths and 13.4 per cent of all cardio- 
vascular deaths as caused by syphilis'". Di- 
seases of these two structures are responsi- 
ble for the ma.)ority of syphilitic deaths. 

The material used in this study was col- 
lected through the cooperation of twenty- 
four health departments of this state. As 
seen in Figure 1, the distribution included 
repre.sentative areas of the state. Each 
death which occurred in these areas during 
1938 was investigated for the presence or 
absence of syphilis by the health officer. The 
investigation was confined to the examina- 
tion of laboratory and medical records and, 
in certain cases, an interview with the pri- 
vate physician who took care of the patient. 
It consisted of 176 cases; 41 per cent were 
white and 59 per cent colored. The sex was 
also about equally divided ; 59 per cent were 
males and 41 per cent females. Slightly 
more than half of the cases were under 
thirty years of age. 

In this study the death rate among syphili- 
tics from all causes was 16.1 per 100,000 of 
the population. It is obvious from Figure 1 
that marked variations existed in this rate. 
This death rate fluctuated in these various 
health jurisdictions from 2 to 65 per 100,000 
population. Among the factors responsible 
for this marked variation were the location 
of the state institution for the insane, the 
availability of medical and laboratory data, 
and the enthusiasm of the investigator to 
"ferret out" syphilis. 

1. Moore. J. E. : The Modem Treatment of Syphilis, Charles 
C. Thomas, published 1933. 



March, 1940 



DEATHS AMONG SYPHILITICS— LEIBY 



157 



PERCam"3ElASe;BiSl1flFUTiaN "AT tlM^ OF OEftTH 

r^r- -["' '"'' :'■" Of : : " '' i : i"";" 

M \ 6ENCRAL, ANO'SVpHlUtIC! PO'PlllLATtoNs 

Safe"'"' " ^IN' ■■^' 

p.' NOR'fH CAftOI-INA 



.-jas**-; 



a^^'--V- 



\ 



2:0 30 40 56 . gg : TO 



30^ TO i^ Ep ' 9p i . :: : ■ ■ 



Fig. 2 

DEATHS FROM ALL CAUSES IN NORTH 
CAROLINA 





AnmntJ the 


Among the Population 


Affe bv 


General Population 


With 


fliiphilix 


Years 


Number Percent. 


Ninnher 


Percent. 


0-9 


7,227 20.0 


36 


20.2 


10-19 


1,621 4.5 


15 


8.5 


20-29 


2,954 8.2 


33 


18.8 


30-.39 


3,065 8.6 


28 


16.1 


40-49 


3,583 10 


29 


16.5 


50-59 


4,353 12.1 


19 


10.8 


60-69 


4,944 13.8 


12 


6.8 


70-79 


4,608 12.8 


4 


2.3 


80-89 


2,723 7.6 






90 -t- 


820 2.3 






TOTAL 


35,898 100.0 


176 


100.0 



Figure 2 shows the age distribution of 
deaths among syphilitics as compared with 
those among the general population of North 
Carolina. Over half of these syphilitics were 
dead before they reached thii'ty years of age, 
whereas, among the general population, one- 
half are dead by forty-five years of age. Be- 
cause an occasional patient reached seventy, 
the average age at death of these patients 
with syphilis was thirty-eight years as com- 
pared with fifty years for the general popu- 
lation ; thus, the lives of these individuals 
with syphilis were shortened about 24 per 
cent. 

The fatality rate at each age of life up 
to fifty is consistently higher for a given 
syphilitic population than for the general 
population (Fig. 2). None of the individuals 
in this study survived beyond seventy ; 
whereas, among the general population, 22.7 
per cent survived beyond this age limit. 

It is appreciated that the age distribution 
of mortality among the syphilitics in this 
study is biased by the fact that detectable 
syphilis is largely dependent upon finding a 
positive Wassermann reaction. In addition, 
the older the population groups studied be- 
yond the peak incidence of the disease, the 



■ 




/ 


i 


%^ 


■ 


/i 






^^^ 












\^Bi^ 




h 






v^^^ 










/ 










^<^^H 


..y 


/ 


, 




, . . . ,^^ 



Fig. 3. .\gc distribution of all people in a given 
population who have ever had .syphilis separated 
according to whether they had detectable syphilis 
(i. e. positive Wassermann), non-detectable syphilis 
(i. e. negative Wassermann) or whether they were 
dead. By permission from Vonderlehr and Usilton 
of U. S. P. .M. S. 

less likely one is to find detectable syphilis 
by the Wassermann test. This decrea.se in 
detectable syphilis is, of course, due to re- 
versals of the Wassermann test either spon- 
taneously or as a result of treatment. As 
was shown (Fig. 3) by Vonderlehr and Usil- 
ton"', approximately one-third of the total 
syphilitic population have a negative Was- 
sermann by the age of forty. This becomes 
of paramount importance to the physician 
when it is appreciated that 23.8 per cent of 
individuals dying of cardiovascular syphilis 
had a negative Wassermann in a series 
studied by Reid'« of Boston. Had all the 
deaths among syphilitics been included in 
this study, it is very likely that the mean 
age at death would have approached closer 
the death rate of the general population. 

Based upon the observed fact that the 
average syphilitic acquired his disease at 
about twenty-two years of age, from this 
study it may be deduced that a person with 
syphilis lives approximately sixteen years 
after the onset of his infection. 

An analysis of the cause of deaths among 
162 of the cases reported reveals 57.5 per 
cent of these deaths may have been directly 
or indirectly due to the activity of the tre- 
ponema pallidum and 42.5 per cent to other 
causes. (Fig. 4) . Moore states that the great- 
est single cause of death from acquired 
.syphilis is cardiovascular syphilis. Di.seases 
of the circulatory system in this study ac- 
counted for 12.2 per cent of the deaths. This 
is approximately one-half higher than the 

2. Vonrlerlelir. R. A. .qnrl I'silton, Ljda .1.: Thy Chance of 
.\cquiring Sypliilis and the Frequency of Its DisaAtrou-S 
Outcome. Venereal Disease Information 19:S!H). 103S. 

3. Reid. W. D. : The Diaffnos-is of Carrliovascular Syohilis. 
Analysis of Clinical and Postmortem Findins.s. \m. Heart 
J. 6:91, 1938. 



158 



NORTH CAROLINA MEDICAL JOURNAL 



March, 1940 




m+rrt 



Ht UU V* PCT w M glB: 



l i ! l M i :!i 



Fig. 4 

DISTRIBITION OF 162 DEATHS AMONG 

SYPHILITICS ACCORDING TO THE 

STATED CAUSE OF DEATH 



Deaths Among SvphiUtie* 
yumber Percent. 



Statfd Catise 
of Death 

Other than Syphilis 52 32.1 

Arsenical Poisoning 7 4.3 

Tuberculosis 8 4.9 

Pellagra 2 1.2 

Syphilis Lesion not Stated. 62 38.3 

Cardiovascular Diseases 19 11.8 

Central Ner^'ous System Diseases 12 7.4 

TOTAL 162 100.0 

rate in the general population for this cause. 
Central nervous system diseases accounted 
for 7.7 per cent of the deaths among sj-phili- 
tics. 

Among 38.3 per cent of the cases in this 
series, syphilis was stated as the cause of 
death, but no clue was given as to the actual 
vital structure involved. In a disease which 
may affect every structure in the body this 
sort of a diagnosis allegorically suggests 
such a dissolution of the human body as was 
applied by that renowned physician-poet, 
Oliver Wendell Holmes to the famous "one- 
hoss shay." Such massive destruction of vital 
structures not infrequently occurs among the 
unborn during the last trimester of an un- 
treated syphilitic pregnancy; however, in 



adults the pathological processes are exceed- 
ingly patchy — destroying areas in the aorta 
in some cases and certain tracts and regions 
of the central nervous system in others. 

Among the causes of death other than 
those attributed to syphilis, tuberculosis and 
arsphenamine dermatitis were the most fre- 
quently observed. As tuberculosis and sj-phi- 
lis are notably diseases of the lower socio- 
economic levels of society, they are probably 
very frequently associated in the same pa- 
tient: however, there are not sufficient cases 
available in this study to draw conclusions 
on this point. 

Arsphenamine poisoning was indicated as 
responsible for 4.3 per cent of the deaths. 
This rate is obviously excessive when com- 
pared to that of Stokes, who has had only 
two arsphenamine deaths in eight years on 
his service in Philadelphia. 

Conclusions 

1. One-half of the annual deaths among 
syphilitics occurred before thirty years of 
age, as compared with forty-five years of age 
for the general population. 

2. Lives of individuals with syphilis are 
shortened about 24 per cent. 

3. The average patient died within sixteen 
years after acquiring the disease. 

4. Approximately twice as many people in 
the syphilitic population die of cardiovascu- 
lar disease as in the general population. 



Laboratory and Clinician. — Much hospital labora- 
torj- work may be regarded as of indirect signifi- 
cance for the indi\-idual ^atient, but aimed at the 
training of better clinicians. When, as sometimes 
happens, it results in the production of poor clini- 
cians, unable to interpret disease except through 
the eyes of the laboratory, its purpose has failed, 
and failed seriously. — Francis W. Peabody: Doctor 
and Patient, New York, The Macmillan Co., 1939. 



Indiscriminate Laboratory Examinations. — In the 
hospital all manner of tests can readily be per- 
formed in obscure or doubtful cases, but in private 
practice the economic factor usually restricts one 
to the tests which most obsiously offer practical 
assistance. Fortunately, however — and this is ap- 
parently contrary to much present-day opinion — 
good medicine does not consist in the indiscriminate 
application of laboratory examinations to a patient, 
but rather in having so clear a comprehension of 
the probabilities and possibilities of a case as to 
know what tests may be expected to give informa- 
tion of value. — Francis W. Peabody: Doctor and 
Patient, New York, The Macmillan Co., 1939. 



March, 1940 



RUPTURE OF THE MEMBRANES— T A YLOE 



15U 



ARTIFICIAL RUPTURING OF THE 

MEMBRANES AS A METHOD OF 

INDUCTION OF LABOR 

John C. Tayloe, M.D. 

Washington, N. C. 

This is not a new method of induction of 
labor; for, on reviewing obstetrical litera- 
ture, we And that this method was first used 
in 1756, by an English mid-wife, Mary 
Donally, who achieved the delivery of a live 
baby from a mother with a contracted pelvis 
who had previously been delivered of two 
full term, still-born babies. Also, in 1783, 
the first physician to perform this simple 
operation was a Dr. Maculay, who ruptured 
the membranes on a similar case, and 
achieved the birth of a live baby from a 
mother with a similar history. 

At the present time there are two theories 
as to what causes the dilatation of the cervix. 
One, the Hydrostatic Wedge Theory, states 
that the bag of water is the dilating agent, 
acting as an even dilator on the cervical 
canal. The other theory, advanced by De- 
wees in 1806, states that as the longitudinal 
muscle in the uterus contracts, the circular 
fibers relax and thus the cervix is dilated 
and pulled up over the pre.senting part. This 
theory aLso states that the membranes and 
liquor amnii act only as a lubricant and pro- 
tecting agent for the baby. 

Those of you who, in the past, have used 
bags and bougies to induce labor have found 
that they did not, in all cases, induce labor; 
that there is a higher fetal mortality con- 
nected with their use ; and that the maternal 
morbidity is higher. Morton*", in a study 
of 132 cases of bag and bougies induction at 
Johns Hopkins Hospital, reports a fetal mor- 
tality of 32 per cent and a febrile puerpura 
in 33 per cent of cases. His report has been 
confirmed by other physicians — among them, 
Moore at the Presbyterian Hospital in Char- 
lotte. 

A simple, easy and efficient method of in- 
ducing labor is by artificial rupture of the 
membranes. This is a valuable therapeutic 
procedure for several reasons : 

(1) It is the easiest method. It is a very 

Read before the Section on Gynecology and Obstetrics, Mcdi 
cal Society of the Slate of Nortli Carolina. Bermuda Cruise, 
May lu, 1939. 

1. Morton, D. G. ; Comparison of Results Obtained in In- 
duction of Labor by .Means of Bougie and Bag, Am. J. 
Obst. and Gynec. (December) 1929. 



simple operation and is done without the aid 
of anesthetics and without special apparatus. 

(2) The danger of infection is no greater 
than from an aseptic vaginal examination, 
and it has the cleansing effect of the liquor 
amnii afterwards as a safeguard. 

(3) It is not necessary to have a foreign 
body (bag or bougie) in the uterus for 
twenty-four hours. 

(4) To a certain extent it imitates nature, 
as it is similar to those ca.ses which have 
spontaneous rupture of the membranes. 

(5) It is sure to induce labor. 

In introducing any therapeutic procedure 
it is necessary to take into consideration the 
indications and contraindications for its use. 
I have found it mo.st useful in cases of 
toxemia of pregnancy which show no im- 
provement under medical care, and those 
with convulsions. Other indications to its 
use are marginal placenta previa, po.st ma- 
turity, abruptio placenta, dy.sentery, and 
fibroids. I have used it also in patients with 
moderately contracted pelvis who had had 
difficult labor with full term, still born chil- 
dren, and in one case of habitual death of 
the fetus between the ninth and tenth month 
of pregnancy. The contraindications to this 
procedure have been marked contraction of 
the pelvis and malposition, and cases where 
a surgical operation has been performed on 
the cervix. 

During the past four years this method of 
inducing labor was used on 59 multiparae 
and 52 primiparae. Of this series of 111 
cases there was one maternal death in a 
patient with severe eclampsia who had had 
no prenatal care. There were five fetal 
death.s — four from toxemic mothers, and one 
a still birth from a mother who had pre- 
mature separation of the placenta. Upon 
analysing these 111 cases we find that the 
latent period — the period from the time the 
membranes were ruptured until the labor 
pains started — was found to average around 
three and a third hours; in the primiparae 
the shortest time was fifteen minutes; the 
longest, eight and one-half hours. The av- 
erage length of labor in the primiparae was 
ten hours and thirty-eight minutes. In the 
multiparae, the latent period averaged about 
three hours. The longest latent period in 
multiparae cases was twelve hours and thirty 
minutes; the shortest, twenty minutes. The 
average length of labor in the cases of multi- 



160 



NORTH CAROLINA MEDICAL JOURNAL 



March, 1940 



parae was seven and one-half hours. The 
longest latent period was found in the cases 
that were furthest from maturity. Pituitrin 
in small doses was used in cases with the 
longest latent periods. All of these patients 
had their membranes ruptured in the hospi- 
tal, and 95 per cent were delivered there. 
The other 5 per cent were allowed to go 
home after remaining in the hospital until 
labor had started and the presenting part 
was well down in the pelvis. Williams of 
Johns Hopkins, and DeLee of Chicago said 
that in all types of labor in a large series of 
cases the average length of labor for a primi- 
para was seventeen and one-half hours, 
and for a multipara, thirteen hours. From 
statistics in my small series of cases, and 
from statistics reported from King'-', Broad- 
head, Macher, Bradford ', Wilson'", and 
Plass"', these figures for the average time 
of labor in primiparae and multiparae were 
reduced 25 per cent, at least. 

Technique: The patient is given a cleans- 
ing enema at 8:00 a. m. The pubic hair is 
shaved and the pubic region washed with 
soap and water. The pubic region and ex- 
ternal genitalia are painted with 4 per cent 
mercurochrome, and one ounce of 4 per cent 
solution of mercurochrome is injected slowly 
into the vagina with a urethral syringe. 
The membranes are then ruptured, using 
aseptic technique, with a pair of long dress- 
ing forceps or any blunt instrument. The 
head is pushed up by the hand in the vagina, 
and as much of the liquor amnii is allowed 
to escape as will. No anesthetic is required. 

The objections to this method of induction 
of labor have been that it causes more intra- 
cranial hemorrhages in infants, and that 
more damage is done to the cervi.x without 
the hydrostatic wedge, and that there is the 
danger of a prolapsed cord. King'-' has 
shown in a large series of cases that these 
conditions do not occur any more than if 
labor goes on with the membranes intact. 
Obstetrical morbidity is about the same as 
in those cases that go through labor with 
the membranes intact. There were no cases 
of infection in my small series. About 10 

2. Kinjr. A. O. : Ci-n iral Dilatifin in Dry Labor and after 
Delibt-rate Early Kupturc ttf llie .Nd'tnbranes. 

3. Bra()fi>r(). \\\ Z. : IiHtuctloii of Labor by Rupture of 
Membranes. South. Med. and Sur. (November) IM33. 

t. Wilson. Leo; Induction of La)>or liy Rupture of the 
Menibranc-s. .\m. J. Obst. and tiyuw.. (February) 19S4. 

5. Plass, E. D. and Seibert. C. \V.; Premature Rupture of 
the .Membranes as a Means of Inducing Labor, .\n). J. 
Obst. and Gynee. (November) IVSfl. 



per cent of them ran a temperature around 
100 from two to three days. Prolapse of the 
cord was not present in anj- of my cases, but 
one case did have a prolapsed arm on which 
a version and extraction was done, success- 
fully. There were no cases of intracranial 
hemorrhages in my series. 

Artificial rupturing of the membranes is 
not recommended as a routine procedure in 
every obstetrical case, but it is recommended 
as a safe, sure and efficient method of in- 
ducing labor when induction of labor is in- 
dicated. 

Disciission 

DR. J. STREET BREWER (Roseboro): It is in- 
teresting to me to recall that when I was in medical 
school, we were taught to keep the membranes in- 
tact as long as possible because premature rupture 
of the membranes would slow up labor. In later 
years, I think we have learned that such is not the 
case. My experience is that labor progresses just 
as well after it starts when the membranes have 
been prematurely ruptured. 

Labor should not be hard and vigorous, particu- 
larly when there is a long latent period. Labor 
may start with a great deal of vigor. I think if 
something is not done to slow down this type of 
labor a little you are likely to get intracranial 
damage. I believe a proper thing to do, in those 
cases where labor starts off vigorously before you 
have dilatation of the cervix is' to give some sort 
of a sedative so that the pains may not be very 
stiong and the patients will not strain in beai-ing 
down until there has been a good deal of efface- 
ment and dilatation of the cervix. In that way 
you lessen the trauma to the baby's head. 

In that connection, I would remind you that, since 
most of these cases' we are dealing with are pre- 
mature infants, you have to be a little careful of 
the administration of morphine to tone down these 
labors. I prefer the use of the barbiturates. 



Emotional .Manifestation. — Although the physical 
manifestations of embarrassment such as blushing 
have long been recognized, the analogue of blushing 
which might be exhibited in palpitation or in spastic 
colitis as a result of emotional factors was over- 
looked. So much attention was focused upon the 
gastro-intestinal and circulatory tract that it was 
forgotten that they were parts of an individual who 
was perhaps expressing in this particular way and 
by these particular symptoms: his emotional con- 
flicts. — Winfred Overholser: The Broadening Hori- 
zons of Medicine, Science, 90; 2338 (Oct. 20) 1939. 



Informing the I'ublic. — Not only the material 
benefits from modern knowledge, but the science 
man's way of working need to be more fully under- 
stood and more widely used. Pasteur did little 
arguing. He presented truth and demonstrated the 
meaning of truth. He withheld nothing for him- 
self. He sometimes expressed regret that so many 
uninformed people could not. or did not, wish to 
understand, but he found encouragement from those 
who did understand. — Caldwell, Otis W.: Some Prob- 
lems of an Educated Minority, Science 89: 2322 
(June 30) 1939. 



Mairh, 1940 



EDITORIALS 



161 



North Carolina Medical Journal 

Owned and Published by 

The Medical Society of the State of North Carolina, 

under the direction of its Editorial Board. 



EDITORIAL BOARD 

Wingate M. Johnson, Winston-Salem 

Editor. 
T. W. M. Long, Roanoke Rapids 

Business Manager. 
Paul P. McCain, Sanatorium, Chairman. 
W. Reece Berryhill, Chapel Hill. 
Coy C. Carpenter, Wake Forest. 
Frederic M. Hanes, Durham. 
Paul H. Ringer, Afheville. 
Hubert A. Royster, Raleigh. . -" 

Address manuscripts and communications to the 

NORTH CAROLINA MEDICAL JOURNAL, 

428 Stratford Road, Winston-Salem. 



March, 1940 



THE PREPARATION OF MANUSCRIPTS 

With the state meeting only two months 
off, those who are on the program will soon 
be preparing their papers. In the desire to 
lighten our editorial task a bit and to achieve 
greater uniformity in future issues of the 
North Carolina Medical Journal, we are 
offering- in this issue a few suggestions for 
the preparation of a manuscript. Most of 
them are taken from Dr. Fishbein's book. 
Medical Writing, which we heartily recom- 
mend to anyone attempting to prepare a 
medical paper. 

Manuscripts should be typed on standard 
size typewriter paper, double-spaced, and 
with liberal margins. Pages should be num- 
bered, and part of the title should appear at 
the top of each page. 

The full title of the paper, the author's 
name with his degrees (M.D. and higher 
degrees) and his address should be at the 
top of the first page. If the paper is from a 
medical school or hospital, the full name of 
the institution and the department should 
be given in a footnote at the bottom of the 
first page, along with the section and meet- 
ing to which the paper was presented, and 
the date of presentation. The form should 



follow that used by the North Carolina 
Medical Journal. 

References to books and articles, and any 
footnotes of the author's, should be typed, 
double-spaced, on a separate page at the end 
of the manuscript, numbered consecutively 
with the pages in the text. The bibliographic 
form and abbreviations used in the Journal 
of the A. M. A. and given in Dr. Fishbein's 
book should be followed exactly. Books and 
articles not referred to in the text should 
not be included, unless a complete bibliogra- 
phy of the subject is given. 

Legends for illustrations, and tabular mat- 
ter should be typed on separate sheets of 
paper, numbered with the text. 

Except in tables, few abbreviations are 
permitted. When there is any doubt, it is 
always best to spell out terms. The sign 'y'c 
is used only in tables. In text matter, "per 
cent" is correct. The word "x-ray" is spelled 
with a small "x". For rules on abbreviation, 
spelling, and numerals in medical writing. 
Dr. Fishbein's book is the most authoritative 
source. 

Case reports should be written with the 
same care that is given to other articles. 
Dr. Fishbein says : "A case report should 
tell its story in clear, straightforward narra- 
tive style. It should not be tran.scribed word 
for word from original records that were 
hastily jotted down at the time the various 
events occurred; the jerky, telegraphic style 
of the record sheet may result in actual 
padding." All irrelevant findings should be 
omitted, and the tenses should be consistent. 
Care should be taken to avoid confusion of 
dates. 

When the paper has been typed, the author 
should re-read it carefully, checking on spell- 
ing and grammar. Corrections should be 
written between the lines in ink, legibly, if 
possible ! 

The North Carolina Medical Journal. 
like most state journals, has been forced to 
adopt the policy of asking authors to pay for 
their illustrations. It will save expense to 
the author if he will omit all illustrations 
which do not add directly to the value of the 
paper. Our engraver makes his rate as 
reasonable as possible. If he so desire, the 
author will be notified as to the cost of his 
cuts before they are made. The statement 
for the cuts will be sent directly from the 
engraver to the author. 



NORTH CAROUNA MEDICAL JOURXAL 



March. 1940 



NORTH CAROLINA'S VITAL 
STATISTIC FOR 1939 

The vital statistics figures for 1939, re- 
cently released by Dr. Carl V. Reynolds, are, 
for the most part, distinctly encouraging. 
The death rate for the entire population is 
the lowest yet recorded — 9 per 1000, as com- 
pared with 9.5 in 1938. This represents a 
saving of 1,911 lives. The infant mortality 
dropped from 68.3 per 1000 live births in 
1938 to 58.5 in 1939. Translated into lives, 
757 more babies survived last year than in 
the year before. In comparing this infant 
mortality with that of some other states, it 
should be remembered that the negro popu- 
lation in North Carolina is 29 per cent, as 
compared with the national average of 10 per 
cent; and that the infant mortality is much 
higher in the colored than in the white race. 

The maternal death rate per 1000 live 
births dropped from 5.6 to 4.8 — comparing 
favorably with the last national rate re- 
corded, in 1937, of 4.9. This means a sav- 
ing of 67 mothers during the year. 

"Last year saw the saving of 357 lives of 
children under 2 years of age in North Caro- 
lina from death from diarrhea and enteritis, 
the rate falling from 29.2 to 18.9 between 
1938 and 1939." 

The pneumonia death rate declined from 
76.8 to 61, saving 537 lives. With the further 
use of sulfapyridine — released for general 
use last March — there .should be a much 
greater saving of lives. An article in the 
Penntsylvania Medical Journal for February, 
summarizing the results in nearly 3000 re- 
ported cases treated with sulfapyridine, 
gives the mortality for all types and ages as 
only 7 per cent. 

The most humiliating figui-es in the report 
record 173 deaths from diphtheria, with a 
rate of 4.9, as compared with 176 deaths and 
a rate of 5 the preceding year — a negligible 
decrea.se. It is to be hoped that the diph- 
theria immunization law enacted by our last 
legislature — thanks to our most efficient Sec- 
retary-Senator, Dr. T. W. M. Long — will do 
much to improve this disgraceful showing. 
Still more important, however, is that the 
family doctors and pediatricians of the state 
redouble their efforts to have all babies 
under their care immunized before they are 
a year old. 



SULFAPYRIDINE VS. SERUM IN 
LOBAR PNEUMONIA 

In an incredibly short time after its intro- 
duction sulfapyridine has been widely ac- 
cepted as our most useful means of combat- 
ting pneumonia. The ease with which it can 
be administered, the fact that it is bacterio- 
static for all types of the pneumococcus, its 
rapid action, and its relatively low danger 
compared with that of the disease itself, 
appeal both to the profession and to the pub- 
lic. In spite of all these advantages, how- 
ever, over the greater expense and more com- 
plicated technique of type-specific serum, the 
latter has its strong advocates, and at times 
the debate becomes rather acrimonious. 

Mason and Stocklen'" have recently pub- 
lished the result of the fairest possible com- 
parison of the two forms of treatment. In 
the Cleveland City Hospital, from February 
1 to May 1, 1939, a series of 66 adult pa- 
tients with lobar pneumonia were treated, 
giving alternate cases serum and sulfapyri- 
dine respectively, "except in some instances 
in which typeable pneumococci were not 
found in the sputum or by lung suction. The 
patient was then given sulfapyridine." 

"Typeable pneumococci were found in 72.7 
per cent of the cases. In the others, hemo- 
lytic streptococci, green streptococci, pneu- 
mococci that did not type, and mixed flora 
were recovered." Three cases of Type III 
pneumococcus were found in each group. 

"Sulfapyridine was approximately twice 
as effective as serum in producing deferves- 
cence by crisis. In 37 per cent of the cases 
treated with serum, fever subsided by crisis, 
compared with 73 per cent in the sulfapyri- 
dine treated cases. 

"Length of hospitalization was definitely 
shorter in the group of patients receiving 
sulfapyridine. Serum treated cases averaged 
19.3 days in the hospital as compared with 
15.9 for those treated with sulfapyridine." 

The average cost of the serum used for 
each patient was $70,07 ; of the sulfapyri- 
dine, $3.03. 

In the .serum treated group there were six 
deaths — a mortality of 18.2 per cent; there 
were no deaths in the sulfapyridine group. 

If not the first, this is certainly one of the 
first reports in which, under conditions as 
nearly as possible similar, alternate cases 

I. Mason. I'lysses G. and Stocklfii, J«»sepli B.: A Cotnpiira 
tive Study of Serum and Sulfapyridine in the Treatment 
gf Lobar Pneumonia. Olilo Stale M. J. 36:1T7 (Feb.) 1910. 



March, 1940 



EDITORIALS 



163 



were treated by serum and sulfapyridine. 
The result speaks eloquently for the effici- 
ency of sulfapyridine. 

In the New York State Journal of Medi- 
cine for February, Kaufman'-' reports a 
series of 81 cases of old age pneumonia 
(bothlobarandbroncho-) treated by sulfapy- 
ridine. The patients' ages ranged from 60 
to more than 90, and the series included 13 
Type III cases. There were 19 deaths in the 
group — a mortality of 23.5 per cent. "But it 
has to be considered that almost all these 
patients had some cardiovascular disease, 
that the previous death rate used to be 75 
per cent, and that there was no selection of 
the cases." In discussing the question of 
serum vs. sulfapyridine, Kaufman concludes 
that : "If one considers the severe strain of 
serum therapy in old age pneumonia sul- 
fapyridine has a wider field of application 
than serum therapy." 

On the other hand, sulfapyridine has a dis- 
agreeable habit of producing renal calculi in 
a certain number of ca-ses. Most of us, if 
we ourselves had pneumonia, would probably 
be willing to take the possible future risk of 
a kidney stone if thereby we could reduce by 
75 per cent our chances of acquiring a tomb- 
stone. It should be remembered, however, 
that both sulfanilamide and sulfapyridine 
should be reserved for real need and not be 
used indiscriminately for minor ailments. 

3. Kaufman. Paul: EfTcct and Toxic Effects of Sulfapyridine 
in Old .\gre Pneumonia, New York State ,1. Med. 10;2iil 
(Feb. 1) 1910. 

* 'f -f * 

THE "COMMON COLD" 

Much has been written but little has been 
learned about the "common cold". A recent 
study"* of several groups of school children 
has brought to light some hitherto unsus- 
pected relationships between the "common 
cold" and communicable disease. It was 
found that, following exposure to such di- 
seases as scarlet fever, measle.s and chicken- 
pox, there would be a sharp peak of upper 
respiratory symptoms among these children, 
occurring near the end of the respective in- 
cubation periods. In one class of 37 pupils 
11 children were absent with colds follow- 
ing exposure of the class to a mild case of 
scarlet fever the previous week. The rest of 
the classes in this school were having excel- 
lent attendance with very few colds. 

The evidence put forward suggests that 
the etiologic agents of various communicable 



diseases may manifest their presence more 
frequently than is recognized by symptoms 
usually tliought of as those of the common 
cold. There is nothing strange in this idea, 
as it has long been recognized that there are 
a large number of abortive and mis.sed cases 
in all epidemics. Many so-called "colds" may 
in reality be missed ca.ses of communicable 
diseases. If this should prove to be true, it 
should be possible to cut down the incidence 
of colds, by attention to fatigue and weather 
exposure following exposure to a communi- 
cable disease. 

The fact that a virus has been indicated 
as the cause of the "common cold" does not 
eliminate other agents. All that has been 
demon.strated is that a certain virus can pro- 
duce cold-like symptoms, and to consider it 
the only causative organism would be highly 
dangerous. The conception that upper respi- 
ratory infections may and probably do have 
a variety of cau.ses has manifold hygienic 
and public health implications. 

I. Turner. Naomi C; rommoti Colds. New Enpland .1. Med. 
;:::iMi (Feli. i) i!i4o. 



THE PLATFORM OF THE AMERICAN 
MEDICAL ASSOCIATION 

1. The establishment of an agency of the federal 
government under which shall be coordinated and 
administered all medical and health functions of the 
federal government exclusive of those of the Army 
and Navy. 

2. The allotment of such funds as the Congress 
may make available to any state in actual need, for 
the prevention of disease, the promotion of health 
and the care of the sick on proof of such need. 

3. The principle that the care of the public 
health and the provision of medical service to the 
sick is primarily a local responsibility. 

4. The development of a mechanism for meeting 
the needs of expansion of preventive medical ser- 
vices with local determination of needs and local 
control of administration. 

5. The extension of meth'cal care for the indigent 
and the medically indigent with local determina- 
tion of needs and local control of administration. 

6. In the extension of medical services to all 
the people, the utmost utilization of qualified medical 
and hospital facilities already established. 

7. The continued development of the private 
practice of medicine, subject to such changes as 
may be necessary to maintain the quality of medical 
services and to increase their availability. 

8. Expansion of public health and medical ser- 
vices consistent with the American system of 
democracy. 



164 



NORTH CAROLINA MEDICAL JOURNAL 



CASE REPORTS 



DUKE HOSPITAL CLINICO- 
PATHOLOGICAL CONFERENCE 

October 18, 1939 

Dr. Lamar Callaway (reading the clinical 
summary) : 

A forty-eight year old white man (Case 
A-25499) was admitted because of chills and 
fever during the preceding five months. 

Familii History: His paternal grand- 
father and great-grandfather both had 
heart trouble all their lives characterized bv 
"double palpitations of the heart". Thev 
were both told that they had "leaking 
hearts." 

Past History: His general health had al- 
ways been good. He had influenza in 1919 
and pneumonia in 1935. He had a Neis- 
.serian infection three years ago which re- 
sulted in urethral stricture requiring dila- 
tion every seven or eight weeks. The patient 
had noticed a thrill at the lower end of the 
sternum since early childhood, and at the 
age of eight years was told that he had a 
"leaking heart". The thrill and heart mur- 
mur had been noted frequently by physicians 
throughout his life, but lie successfully 
passed three insurance examinations wheii 
he was twenty-four years of age. 

Present Illness: Five months previously 
he had had a febrile illne.ss. accompanied by 
cough and generalized muscular aches. He 
had a chill at the on.set and another about 
one week later, and it was thought that he 
had malaria. The fever and chills persisted 
in spite of large do.ses of quinine. He had 
spent the month previous to admission in a 
nearby hospital, and while there was given 
three tablets of sulfapyridine three times 
daily for eight days. The chills ceased. Two 
weeks previous to admission he had experi- 
enced a sudden sharp pain in the lower right 
chest, associated with dyspnea and marked 
pain on deep inspiration. Three days later 
he coughed up bloody mucus. The pleuritic 
pain disappeared in a week. Ten days be- 
fore admission he noted swelling of the feet, 
and several red. pin-point spots on the feet 
and ankles. He has lost about twenty pounds 
in weight. 

Physical E:cuniimition: The temperature 



March, 1940 

was 39.5T., pulse 20, respiration 26. The 
blood pressure was 166 64 in both arms. 
The patient was fairly well developed and 
nourished and did not appear particularly 
ill. The respirations were a little rapid, but 
not difficult. Numerous petechiae were scat- 
tered over the feet and lower legs, and a 
few over the trunk and arms. Mucous mem- 
branes were pale. The teeth were very ca- 
rious. Marked pyorrhea was present. Ar- 
terial pulsations were observed in the neck 
but there was no engorgement of neck veins. 
A thrill could be felt over the lower end of 
the sternum. The heart was moderatelv en- 
larged to the left. A loud, hansh, .systolic 
murmur could be heard over the entire pre- 
cordium and also over the posterior left 
chest, but best over the lower end of the 
.<ternum. Lungs were negative except for a 
few rales at both ba.ses posteriorly. There 
was moderate abdominal distention but no 
shifting dullness, and no masses or organs 
could be felt. There was slight pitting edema 
over both feet and ankles: no clubbing of 
the fingers or cyanosis of the nail beds. 

Accessory Clinical Findivgs: Hgb. 7.7 
Gm. or 49 per cent; RBC 2,370,000; Color 
Index 1; WBC 11,680. Differential: PMN 
95 per cent, of which 39 per cent were of 
the immature variety; LL 3 per cent; SL 1 ; 
M. 1: slight anisocytosis of the red blood 
cells. The sedimentation rate was 18 mm. 
per hour, corrected. Blood Was.sermann and 
Kahn reactions were negative. Urine at the 
time of admission showed sp. gr. of 1.008, 
albumin 3 plus, and 20 RBC per high power 
field in the centrifuged sediment with a 4 
plus benzidine reaction. The specific gravity 
of the urine throughout the hospital course 
was never above 1.012. Marked albuminuria 
persisted. At times there were as many as 
200-300 RBC per high power field in the 
centrifuged urinary sediment. Stool exami- 
nation was negative. NPN at the time of 
admission was 75 mg. per cent. Phenolsul- 
fonphtalein test showed an excretion of only 
22 per cent in two hours. Admission blood 
cultures yielded 15 colonies of alpha hemo- 
l.vtic streptococci (viridans) per cc. Elec- 
trocardiogram showed normal sinus rhythm 
with levogram predominant, and the con- 
clusion was that the record did not indicate 
myocardial disease. Fluoroscopy and a film 
of the chest were reported as consistent with 
cardiac hypertrophy, a small congenital de- 



March, 1940 



CASE REPORTS 



165 



feet explaining the long-standing cardiac 
signs. 

Course hi Hospital: The patient was given 
a soft diet supplemented by accessory vita- 
mins, iron and liver. He was digitalized and 
fluids were re.stricted to 2,000 cc. each day. 
The edema persisted in spite of these 
measures, and a check on the plasma protein 
revealed a total protein of 5.4 gm. per cent 
with albumin of 2.3 gm. per cent and globu- 
lin of 3.1 gm. per cent, with an A/G ratio 
of .74. (Dr. Callaway, commenting: The 
blood protein was not particularly low. 
However, in the normal case we expect the 
total proteins to be about 6.8 gm. per cent.) 
He was given a total of 1,250 cc. of blood in 
four tran.sfusions. Following the last trans- 
fusion the hematuria became more pro- 
nounced and he was given no blood during 
the nine last hospital days. The NPN con- 
tinued to rise, and two days previous to 
death a pericardial friction rub could be 
heard. On the following day the NPN was 
found to be 150 mg. per cent. Three days 
before death he was given sulfapyridine in- 
travenously. Immediately after the drug 
was administered the concentration was 41 
mg. per cent and in eight hours had fallen 
to 3.6 mg. per cent. The drug was not given 
with the idea that it would be life-saving, 
but to see if the blood could be .'iterilized by 
a high concentration of the drug. On the fol- 
lowing day, however, there were 60 colonies 
of alpha hemolytic streptococci per cc. of 
blood. 

On the day before death, the plasma CO/2 
combining power was 24 vol. per cent. In 
spite of intravenous molar lactate the CO/ 2 
combining power was 28 vol. per cent on the 
day of death. 

During the first ten hospital days the pa- 
tient's temperature was seldom below 38°C. 
and on two occasions was above 40. He had 
one chill. During the last six days of his life 
the temperature only on two occasions was 
above 37. The WBC count varied from 6,000 
to 17,000. At the time of death the Hgb. 
was 48 per cent. 

On the sixteenth hospital day he com- 
plained of slight precordial pain and expired 
quietly a few minutes afterward. 

Dr. Callaway : In summarizing, we have 
a forty-eight year old white man who ap- 
parently had been in good health until five 
months before admission. He gave a family 



history of cardiac disease. He himself had 
had a leaking heart since eight years of age 
and we must assume that he had had .some 
heart disease. Until five months before ad- 
mission he got along all right. The find- 
ings probably indicate subacute endocardi- 
tis superimposed on a previously damaged 
heart. As we know, 5 per cent of patients 
with congenital heart disease develop sub- 
acute bacterial endocarditis. Eighty per cent 
of cases of subacute bacterial endocarditis 
show rheumatic heart disease. 

This man's illness began about five months 
before admission with chills and fever. Fol- 
lowing that there was pain in the chest 
which was probably pulmonary infarction. 
There were petechiae on the extremities 
probably due to emboli. The patient also de- 
veloped nephritis ; the NPN went up con- 
siderably and there was uremia. Again I 
interpret this as an embolic phenomenon. 
Looking at the che.st plate we see that he 
does not have a great deal of left sided 
cardiac enlargement. A patent interventric- 
ular septum is believed to be present because 
of: (1) a hi.story of leaking heart and heart 
disease since early childhood, (2) superim- 
posed subacute bacterial endocarditis with 
petechiae, emboli, etc., (3) physical signs 
showing globular heart, .systolic thrill and a 
harsh loud systolic murmur heard best at 
left lower border of sternum, (4) x-ray and 
fluoro.scopic evidence consistent with patent 
septal defect. He did not respond to molar 
lactate pi'obably because of a failing circula- 
tion. For the anatomical diagnosis we a.s- 
sume that the patient had : Congenital heart 
disease ; patent interventricular septum ; sub- 
acute bacterial endocarditis ; old pulmonary 
infarct; glomerulonephritis; cardiac hyper- 
trophy; pericarditis (uremic?, embolic?). 
He may have had some other valvular 
lesions. Not having seen the patient, I can- 
not diagnose anything from the notes I have 
except patent interventricular .septum. He 
probably showed an old pulmonary infarct. 

Dr. Roger Baker: May we see the x-rays? 

Dr. William Wallace: First of all the 
lung at the right base shows a line of thicken- 
ing at the lower border between the upper 
and middle lobes. This is the only evidence of 
previous pulmonary infarct. He did experi- 
ence pain at the time of infarction in the 
right base. As for the heart, it is slightly 
enlarged. It is not markedly globular, but 
the tip of the apex is rounded. My first im- 



16G 



NORTH CAROUNA JfEDICAL JOURNAL 



March. 1940 



pression was that of mitral disease. We re- 
peated the examination by fluoroscopy and 
gave him barium, and made a differentiation 
in favor of ventricular septum defect be- 
cause the left auricle was not enlarged pos- 
teriorly and did not encroach upon the eso- 
phagus. 

Dr. Baker: Would any one like to go 
fuiiher and place the lesion on one side of 
the heart or the other? 

Dr. Dick : The fact that embolic pheno- 
mena were noted in the form of a pulmonary 
infarct sugge.sts that the lesion was on the 
right side of the heart. 

Dr. Baker: Which way would blood cir- 
culate through a -septal defect? 

Dr. Callaway: From left to right, be- 
cause of the greater pressure in the left side. 

Dr. Baker: If that is so the lesion could 
be on the left side and an embolus to the lung 
could come from the left side of the heart, 
pa.ss through the septal defect and through 
the right side of the heart to the lung. How- 
ever, during diastole, the blood could pass in 
either direction through the patent septum. 

Dr. Baker (demonstrating organs) : The 
heart has a vegetation 2 cm. in diameter on 
the infundibular cusp of the tricuspid valve 
(Fig. 1). The valve leaflet has been eroded 
and is ruptured. The interventricular defect 
is in the upper part of the ventricular sep- 
tum, in the fibrous portion, and is as large 
as a lead pencil — that is, a little less than 1 
cm. in diameter. The vegetation extends as 
a prong from the tricuspid valve through 
the ."septal defect and pre.'^ents in the chamber 
of the left ventricle ( Fig. 2 ) . Very intere.st- 
ingly, this prong is not attached to the walls 
of the defect itself, but lies free in the open- 
ing. It seems then that the original growth 
was on the tricuspid valve at a point where 
blood passing through the defect would im- 
pinge on the valve. The vegetation on the 
tricuspid valve has formed implants on that 
wall of the right ventricle away from the 
septum, and here chordae tendineae have 
been .■severed by erosion. This accident, 
coupled with the perforation of the valve 
leaflet, caused insufticiency of the tricu.spid 
valve. This is to be correlated with the dila- 
tation of the right side of the heart. 

The pulmonary and aortic valves appear 
normal. 

At the base of the right lung is an infarct. 
It is both white and yellow. The yellowness 




Fig. L Vegetation (V) and ulceration of tricuspid 
valve leaflet. Interventricular defect (arrow) to 
left. Note stump (s) of attachment of chordae 
tendineae and mural vegetative involvement in right 
lower comer. 

Fig. 2. Prong of vegetation (arrow) extending 
through the interventricular defect into the left ven- 
tricle. .\ortic valve and aorta above. Chamber of 
left ventricle below. 



is probably due to hemosiderin, which would 
take some time to form. The clinical history 
indicates that the infarction occurred five 
weeks before death. The appearance of the 
infarct is consistent with that time interval. 
The lungs are heavy, due to congestion. The 
spleen is a typical acute splenic tumor. The 
kidneys are enormous — two or three times 
normal size — and studded with petechial 
hemorrhages. The liver presents marked 
chronic passive congestion. 

A micro.scopic .section (projecting sections 
on screen) of the tip of a portion of vegeta- 
tion indicates that the latter is composed 
largely of Gram-positive cocci. There is a 
central necrotic area and a peripheral zone 
of fibrin and red cells. Sections of the kid- 



Maidi, 1940 



CASE REPORTS 



107 



neys show red cells in the tubules. These 
foci correspond to the petechiae noted on the 
surfaces of the kidneys and to the finding of 
red cells in the urine during life. In the 
glomeruli are thrombosed capillaries. The 
capsules show "crescent" formation on oc- 
casion, but these are all of recent origin. 
No glomerular or arteriolar changes indi- 
cative of kidney disease antedating the strep- 
tococcus septicemia are seen. The cardiac 
hypertrophy is therefore not to be associated 
with pre-existent renal disease. It is im- 
possible for me to say which of the follow- 
ing factors was chiefly responsible for the 
cardiac hypertrophy: (1) hypertension 
(which was present, with high pulse pres- 
sure), (2) patency of interventricular .sep- 
tum, (3) tricuspid insufficiency, or (4) the 
recent renal damage. 

Anatomical Diagnosis 

(No. 2570) 

Congenital heart disease; patent interven- 
tricular septum. 

Cardiac hypertrophy (450 grams). 

Subacute bacterial ulcerative endocarditis 
(streptococcus viridans) of tricuspid valve 
with remarkable projection of prong of vege- 
tation through septal defect; implants of 
vegetation on mural endocardium with 
erosion of chordae tendineae. 

Infarct of right lung with adjacent jileural 
adhesions. 

Tricuspid insufficiency. 

Chronic passive congestion of viscera. 
Pulmonary and subcutaneous edema. As- 
cites. Hydrocele. 

Streptococcus viridans septicemia with 
hemorrhagic glomerulonephritis. Uremia. 
Fibrinous pericarditis. Acute splenic tumor. 
Focal necroses and ulcerations of intestinal 
mucosa. 

Mild benign adenomatous jirostatic hyper- 
trophy. 

Dr. Baker: The interest in this case lies 
in the fact that there was a congenital 
anomaly in relation to which bacterial endo- 
carditis developed. It is suggested that the 
location of the vegetation is at a point at 
which a stream of blood would impinge when 
it passed through the abnormal opening in 
the septum. Such forceful continuous con- 
tact of the stream of blood may be the es- 
sential reason why the bacterial growth has 
developed at just this site. The manner in 
which the growth extends through the open- 



ing also suggests that blood must have 
passed not only from left to right as one 
would expect but also from right to left, per- 
haps during diastole. 

Reference to the literature ( Maude Ab- 
bott, 1925)"' reveals the following interest- 
ing conclusion as the result of the study of a 
series of cases similar to the present one : 

"In septal defects and patent ductus .... 
the (bacterial) lesion is usually right-sided 
and gives unmistakable evidence, both by 
this fact and by the presence of infarcts in 
the pulmonary circulation and absence of 
those on the systemic side, that the .shunt in 
these abnormal communications is arterial- 
venous under the ordinary conditions of the 
circulation in health." 

Here is an autopsy specimen from another 
case in which bacterial growth occurred on 
the pulmonary artery at the opening of a 
patent ductus. No growth occurred on the 
aorta at the other end of the patent ductus. 
This is in keeping with the observations of 
Abbott. 

Therefore, when bacterial endocarditis de- 
velops in cases of congenital defect of the 
interventricular septum, the vegetations will 
probably develop on the right side primarily 
and involve the tricuspid valve. 

I. Abbott, M. : Inflammatory Processps in Canliovasinilar 
Defei'ts, Ann. Clin. Med. 4:189. l!rj.',. 



CLINICO-PATHOLOGICAL 

CONFERENCE 

City Memorial Hospital 

Winston-Salem 

Mr. R. A. M., a white male fifty-nine years 
of age who had been living as a tramp, en- 
tered the hospital May 4, 1939, with swell- 
ing of the legs, pain in the left leg, and 
chills. The patient's family history was nega- 
tive. The only important past history ob- 
tained was that of gonorrhea and syphilis 
twenty-thirty years ago treated by seventeen 
".shots" in the arm, and gall bladder di.sease 
fifteen years ago. Recently he had had mod- 
erate anorexia associated with a desire to 
vomit. The present illness began about 
twelve days before admi.ssion, with swelling 
of the ankles, which gradually extended up 
the legs. Three days before admi.ssion he 
began to have pain in the region of the left 
knee, which had become increasingly tender. 
The next day, while walking on the road, he 
became exhausted and spent the night in the 
woods sleeping by a camp fire. He had three 



1(!8 



NORTH CAROLIXA MEDICAL JOURNAL 



March. 1940 



chills during the night. His diet had been 
limited almost entirel.v to eggs, milk, rice 
and cereal with very little green vegetables 
and fruit. He appeared anxious and showed 
evidence of having lived under poor hygienic 
conditions. The sclera were icteric, the pupils 
were round and equal, and reacted to light 
and accommodation. The tongue was coated, 
the breath foul, the teeth in poor condition, 
and the pharynx reddened. The lungs were 
normal. The heart was enlarged to the left. 
The apex impulse was palpable in the an- 
terior axillary line in the fifth interco.stal 
space. The heai't sounds were distant with 
a soft systolic blow over the mitral area. 
The second heart sound was slurred. No 
thrill was palpable. The rate was 84 with 
regular rhythm, and the blood pressure was 
120/70. The peripheral vessels were thick- 
ened but not .sclerotic. There was generalized 
edema of the abdomen, especially marked in 
the sacral region. The liver was palpable at 
the costal margin. The spleen was not pal- 
pable. Free fluid was present in the abdo- 
minal cavity. Both legs were edematous and 
the left leg was red and tender with a small 
bleb present above the knee. Pulsation was 
pre.sent in the dorsalis pedis vessels and the 
femoral vessels. The genitalia were edema- 
tous. No abnormal neurological signs were 
present. The temperature on admission was 
98.6° ; pulse, 84 ; and the respiration, 20. 

Lahoratortj Work: 

Urine: Negative except for 15 to 20 W. B. C. 

Bile present. S. G. 1.023. 
Blood: 

R.B.C. 3,300,000 Hb. 12 grams 

W.B.C. 13,150 

Stabs 23' r 

Segs 60% 

Lymphs 9% 

Monos I'/r 

Kline: Doubtful. 

Stools: Negative for parasites, ova and blood. 
Van den Bergh: Direct reaction, positive. 
Icterus Index; 10 
N. P. N.: 40 
Sugar: 102 

Smear from blister fluid on leg showed staphy- 
lococcus. 
Blood albumin: .3.27 grams. 
Globulin: 1.48 grams. 
Blood culture: Negative in 48 hours. 

X-ray examination of the chest on May 6 
showed congestion of the pulmonary vessels 
in both bases, more marked on the right. 
There were adhesions between the pleura 
and the pericardium and a slight amount of 
fluid in the costophrenic angle. The cardiac 
outline was not enlarged, but the contour of 



the left ventricle was concave. During the 
patient's stay the temperature rose to 101.5° 
on alternate days for the first eight days. 
This was thought to be due to lymphangitis 
of the left leg, and the patient was given 
sulfanilamide. After the eighth day the 
temperature remained normal. By May 12 
the patient had developed fluid in the right 
base and pulmonary edema. The heart 
sounds at this time were of poor quality. 
The heart rate was 70 with digitalis. The 
patient showed a gradual downhill course. 
The pulse ranged from 80-100. During the 
last twelve hours of life the pulse rate in- 
creased steadily from 108-146. The temp- 
erature at the .same time rose from 96°F. to 
102. 6°F, and the respirations increased from 
24-42. Just before death the patient regur- 
gitated a large amount of dark brown blood, 
blood. 

Clinical Discuttxioii: (Dr. R. L. McMil- 
lan) : This case presents several points of 
interest in differential diagnosis. The prob- 
lem is complicated by several factors. In the 
first place, the history does not seem ade- 
quate, as the patient apparently was a poor 
witness. 

The history shows a primary complaint of 
progressive swellings of the feet and legs, 
and yet there was no dyspnea, orthopnea, 
palpitation or other symptom of congestive 
heart failure. Furthermore, we have the 
roentgenologist's assurance that the heart 
was not enlarged. One must therefore con- 
clude that this man's final illness was not 
heart failure, except as a very late terminal 
affair. 

The history of pain in the left knee, and 
finding the left leg hot. red, swollen, and 
tender indicates either cellulitis or thrombo- 
phlebitis. 

The large amount of abdominal ascites, 
history of some liver disease fifteen years 
ago, icteric index of 10, anorexia, nausea, 
and finally hematemesis, lead to the diag- 
nosis of cirrhosis of the liver. 

There was likely a terminal pneumonia 
and some heart failure with pulmonary 
edema in the end. 

In summary then, it seems likely that this 
patient had cirrhosis of the liver, cellulitis 
of the leg, generalized arterio.sclerosis, mul- 
tiple vitamin deficiency, and terminal pneu- 
monia. 

Autopsy: The peritoneal cavity contained 



March, I'JIO 



HUM.KTIN BOARD 



1C>0 



over two liters of cloudy, red fluid. The right 
pleural cavity contained one liter of cloudy, 
straw-colored fluid, and the left pleural cavi- 
ty contained 300 cc. The liver weighed 
1,000 grams and was typical of Laennec's 
cirrhosis. The stomach and small intestines 
were distended with black semi-liquid blood 
and blood clots. The esophageal veins were 
dilated and one of them was ruptured. The 
left lung was soft and hemorrhagic and the 
bronchi contained black, semi-liquid material 
indicating aspiration of gastric contents. 
The mitral leaflets showed healed endocar- 
ditis probably rheumatic in origin. There 
was no evidence of coronary disease. 



BULLETIN BOARD 



State Board of Health 

Dr. R. B. Aiken, industrial hygiene physician for 
the Vermont State Board of Health, made a tour 
of the state with Dr. T. F. Vestal, Director of the 
North Carolina Division of Industrial Hygiene. 

They visited foundi-ies, granite worl<s, woolen 
mills, knitting and pulp mills. Practically all these 
industries exist in Vermont, Dr. Aiken explained, 
and added: "It was suggested by the National Di- 
vision of Industrial Hygiene that I come to North 
Carolina in order to see practical demonstrations 
of just how these occupational problems are being 
handled from both a medical and an engineering 
standpoint." 

Nutritional Study 

North Carolina, through the medium of its State 
Board of Health, in cooperation with other impor- 
tant agencies, is preparing to take an advanced step 
in the field of nutrition. 

The General Committee on Nutrition met at the 
call of Dr. Carl V. Reynolds, State Health Officer, 
in the new State Laboratory of Hygiene building, 
and discussed plans for the improvement of the 
nutritional status of the people of North Carolina. 
As a first step, it was determined to launch a state- 
wide fact-finding program, to be carried on through 
the various agencies represented. 

Cooperating Agencies 

The committee, organized on a state-wide basis, 
is composed of the following members from the 
participating agencies: 

Department of Public Instruction: Charles E. 
Spencer, representing Superintendent Clyde A. Er- 
win; Miss Virginia Ward. 

Duke University School of iVIedicine: Dr. W. C. 
Davison, dean; Dr. William A. Perlzweig; Dr. G. S. 
Eadie; Dr. W. J. Dann. 

Rockefeller Foundation: Dr. John A. Ferrell, Dr. 
John F. Kendriek, Dr. D. F. Milam. 

Department of Public Welfare: Mrs. W. T. Bost, 
commissioner; Dr. James Watson, head of the Di- 
vision of Mental Hygiene. 

Department of Agriculture: Dr. E. C. Constable, 
representing Commissioner W. Kei'r Scott; Dr. C. 
W. Pegram. 



Extension Division, State College: Dean I. 0. 
Schaub, Dr. John W. Goodman. 

North Carolina Medical Society: Dr. Cloyce R. 
Tew, representing Dr. T. W. M. Long. 

North Carolina College for Women: Miss Mar- 
garet Edwards. 

University of North Carolina, Division of Public 
Health: Dr. H. W. Brown. 

State Board of Health: Dr. G. M. Cooper, Dr. E. 
S. Lupton, Dr. J. C. Knox, Dr. R. E. Fox, Dr. Walter 
Wilkins. 

General Purposes 

Dr. Reynolds, who called the conference and pre- 
sided, explained its pui^poses and outlined plans for 
a cooperative nutritional study. 

The purpose of the study, which is being set up 
in cooperation with the Duke University Medical 
School, "is to get an accurate measure of the present 
nutritional status of selected areas and groups of 
the population," Dr. Reynolds explained. The first 
studies, including blood te.sts of patients, will be 
conducted in an area within thirty miles of Durham. 

The state-wide nutrition committee will supervise 
the study and later formulate a practical program 
for improving the nutritional status of the whole 
population. 



New Building for State Laboratory 
OF Hygiene 

On February 21 the Clarence Albert Shore Me- 
morial building of the State Laboratory of Hygiene 
was fonnally dedicated. Among the speakers in the 
three-hour ceremony were Governor Hoey, who paid 
tribute to Dr. Shore and to other pioneers in North 
Carolina's public health program, and Dr. John A. 
Ferrell, associate director of the International 
Health Division of the Rockefeller Foundation, who 
was associated with Dr. Shore in the early days of 
the laboratory. Dr. Ferrell, speaking of the new 
.$200,000 building and a $180,000 farm laboratory 
nearing completion, said: "This excellent labora- 
tory set-up is only approximated by Georgia in the 
states of the South." 

Following the speeches of the morning. Governor 
Hoey participated in the unveiling of a memorial 
tablet for Dr. Shore. 



News Notes from Duke University 

School of Medicine and Duke 

Hospital 

The following clinics have been held recently: 

January 26, "Testosterone Therapy in Hypogeni- 
talism", by Dr. Samuel A. Vest, Jr., Professor of 
Urology, University of Virginia Medical School. 

February 27, "Appendicitis", by Dr. John M. T. 
Finney, Jr., Associate in Surgery, The Johns Hop- 
kins University School of Medicine. 

February 28, "Influenza", by Dr. Thomas Francis, 
Jr., Professor of Bacteriology, Bellevue Medical 
School. 

Through the grant of $175,000 from The Rocke- 
feller Foundation, a department of Psychiatry and 
Mental Hygiene has been established at Duke Uni- 
versity, to be operated beginning September 1, 1940. 
The Highland Hospital, at Asheville, N. C, a gift 
to the University last year by Dr. Robert S. Carroll, 
will be used in connection with this department. 
Dr. Richard S. Lyman, now of the Phipps Psychiatric 
Clinic, The Johns Hopkins University, has been ap- 
pointed head of the new department. 



170 



NORTH CAROLINA MEDICAL JOURNAL 



March. 1940 



News Notes from the School of Medicine 
OF THE University of North Carolina 

Sponsoi-ed by the School of Medicine and the Ex- 
tension Division of the University of North Caro- 
lina, the Third Post Graduate Course in Medicine 
at Charlotte began on Tuesday, February 6. Fol- 
lowing is the program for the entire course: 

February 6 — "Problems Presented by the Symp- 
tom Jaundice" — Dr. A. M. Snell, Mayo Clinic, 
Rochester, Minnesota. 

February 13 — "The Diagnosis and Treatment of 
Vitamin Deficiencies in Man" — Dr. Tom Spies, 
Professor of Medicine, and Director of Re- 
search Nutrition, University of Cincinnati Col- 
lege of Medicine, Cincinnati, Ohio. 

February 20 — "Meniere's Disease and Other Verti- 
goes: Cianial Neuralgias and Other Diseases 
and Lesions of the Cranial Nerves" — Dr. Wal- 
ter E. Dandy, Pi-ofe.ssor of Neurology, Johns 
Hopkins Medical School, Baltimore, Md. 

March 5 — "The Diagnosis and Treatment of Syph- 
ilis" — Dr. Udo J. Wile, Professor of Derma- 
tology and Syphilology, University of Michi- 
gan, Ann Arbor, Mich. 

March 12— "Thyroid and Other Endocrine Dis- 
orders" — Dr. J. H. Means, Jackson Professor of 
Clinical Medicine, Harvard University School 
of Medicine, Boston, Mass. 

March 19 — "Management of the Menopause"— Dr. 
Emil Novak, Professor of Gynecology, Johns 
Hopkins School of Medicine, Baltimore", Md. 

Clinics are held at 4:30 p. m.. followed by dinner 
at 7:00 p. m.. and a lecture at S:00 p. m. 

Post-graduate courses will begin in Raleigh on 
March 1.5 and in Goldsboro on March 16. 



News Notes from the Wake Forest 
Medical School 

Dr. C. C. Carpenter, Dean of the Medical School, 
attended the Annual Congress on Medical Education 
held in Chicago on February 12 and 13. Dr. Car- 
penter remained in Chicago for conferences with 
various medical educators, oft'icials of the American 
Medical Association, and Deans of other leading 
schools, on the facilities and educational program 
of the school as it will be when moved to Winston- 
Salem and expanded to a four year institution. All 
consulted were enthusiastic in their praise. A great 
majoritv of the items on which a medical school is 
rated placed the School in the upper ten per cent, 
when compared with existing four year schools. 

The Medical School sponsored a Student Convoca- 
tion for all departments of the college on January 
8. Dr. Herbert S. Wells, Associate Professor of 
Physiology at Vanderbilt University School of Medi- 
cine, was the guest speaker. His subject was, "The 
Physiology of Living". 

Dr. Robert P. Morehead, Assistant Pi-ofessor of 
Pathology, was guest speaker at the Second Dis- 
trict meeting of the South Carolina Medical Society 
held at Batesburg on February 1, 1940. His sub- 
ject was, "Appendicitis — A Clinical and Pathological 
Study of 5,644 Cases". 

Dr. Camillo Artom, Professor of Bioehemi.stry, 
was recently selected, along with Dr. L. Emmett 
Holt, Jr., of Johns Hopkins and Dr. W. R. Bloor, of 
the University of Rochester, by the Carolene Prod- 
ucts Co, to make a special study of fat metabolism. 



North Carolina Mental Hygiene Society 

The Fourth Annual Meeting of the North Caro- 
lina Mental Hygiene Society wis held at the Wash- 
ington Duke Hotel in Durham on Februaiy 16, with 
Dr. W. R. Stanford presiding. The general topic 
for the afternoon program, which began at 2:30 
o'clock, was Mental Hygiene of the Child. The 
speakers for this meeting were W. D. Perry, Ph.D., 
Director of the University Testing Service, and Ad- 
viser for the General College, University of North 
Carolina, whose subject was "The Child in the 
School"; Richard F. Richie, M.D., Assistant Direc- 
tor, Division of Mental Hygiene, State Board of 
Charities and Public Welfare, who spoke on "The 
Child in the Community"; and Frank Howard Rich- 
ardson, M.D., of Black Mountain, who spoke on 
"The Child in the Home". A business meeting was 
held at 4:30 o'clock, and an iirformal dinner at 7:00 
o'clock. The guest speaker at the evening meeting 
was Dr. C. C. Burlingame, Psychiatrist-in-Chief of 
the Neuro-Psychiatric Institute of the Hartford Re- 
treat, Hartford, Connecticut, whose topic was "Youth 
and Middle Age — Neglected Ages of Man". 



Tri-State Medical Association 

The Forty-Second Annual Meeting of the Tri- 
State Medical Association of the Carolinas and Vir- 
ginia was held at the John Marshall Hotel in Rich- 
mond on February 26 anil 27. Among the speakers 
were Dr. Graham Reid of Charlotte, who spoke on 
"Intubation of the Small Intestine as It is Related 
to Intestinal Obstruction"; Dr. G. Carlylc Cooke of 
Winston-Salem, who discussed "Some Chemical Prob- 
lems Confronting the Surgeon"; Dr. R. B. Davis of 
Greensboro, who gave a paper on "The Differential 
Diagnosis Between Chronic Appendicitis and Chronic 
Disease Conditions of the Right Ureter"; Dr. W. S. 
Cornell of Charlotte, whose subject was "The Selec- 
tion of Patients with Gallbladder Disease for Surg- 
ery"; Dr. Deryl Hart of Durham, who spoke on 
"Sterilizing the Air in the Operating Room with 
Bactericidal Radiation"; Dr. Jack Mickley of Tabor 
City, who gave a paper on the "Treatment of 
Venereal Ulcers in General Practice"; and Dr. R. 
S. Anderson of Rocky Mount, who gave an illus- 
trated lecture on "Four Problems Concerning Ade- 
nomatous Goiter". Guest speakers were Dr. Charles 
F. Geschickter of Baltimore, who gave an address 
on "Some Phases of the Cancer Problem"; Dr. A. 
C. Broders of Rochester, whose subject was "Cancer 
as We Know It Today"; Dr. Temple Fay of Phila- 
delphia, who gave an address on "Refrigeration in 
Cancer"; Dr. Seale Harris of Birmingham, who ad- 
dressed the Association on "The Diagnosis and Die- 
tary Management of Hyperinsulinism"; Dr. Maurice 
Protas of Washington, who spoke on "The Insulins 
and Their Uses"; Dr. Emil Novak of Baltimore, 
whose address was on "The Treatment of Primary 
Dysmenorrhea"; and Dr. Lawrence F. Woolley of 
Towson, Md., who gave an address on "Morbid Fear 
and Anxiety as a Cause of Physico-Pathological 
Changes in Structure". 

Dr. C. J. Andrews of Norfolk is president of the 
Association for the coming year, and Dr. A. G. Bren- 
izer of Charlotte was named president-elect. Dr. 
R. B. Davis of Greensboro, Dr. J. B. Davis, Jr., of 
Lynchburg, and Dr. G. R. Wilkinson of Greenville, 
S. C, were elected vice-presidents. Elected to fill 
vacancies on the council were Dr. J. R. Young of 
Anderson, S. C, Dr. R. P. Morehead of Wake Forest, 
and Dr. 0. B. Darden of Richmond. 



March, 1940 



BULLETIN BOARD 



171 



The American College of Physicians 

The Twenty-Fourth Annual Session of the Ameri- 
can College of Physicians will be held in Cleveland, 
Ohio, April 1-5, 1940. General headquarters for the 
meeting will be in the Public Auditorium. 



American Board of Internal 
Medicine, Inc. 

The American Board of Internal Medicine will 
conduct oral examinations just previous to the meet- 
ing of the American College of Physicians in Cleve- 
land and just in advance of the meeting of the 
American Medical Association in New York City. 

Applicants who have successfully passed the writ- 
ten examination and plan to take the oral examina- 
tion in 1940, should advise the office of the Secre- 
tary at lea.-it six weeks in advance of the date of 
the examination they desire to take. 

The next Nvritten examination for 1940 will be 
given on October 21. Applications for this ex- 
amination must be filed in the Secretary's office by 
September 1. 

Application forms may be obtained from Dr. Wil- 
liam S. Middleton, Secretary-Treasurer, 1301 Uni- 
versity Avenue, Madison, Wisconsin, U. S. A. 



Second Call for the Decennial Meeting 

OF THE Convention for the Revision of 

THE Pharmacopoeia of the United 

States of America 

In compliance with the provisions of the Consti- 
tution and By-Laws of the United States Pharma- 
copoeial Convention, I hereby issue this second call 
to the several bodies entitled under the Constitution 
to representation therein to appoint three delegates 
and three alternates to the Decennial Meeting of the 
Convention for the Revision of the Pharmacopoeia 
of the United States of America, which is to meet 
in Washington, D. C, on May 14, 1940. 

WALTER A. BASTEDO, M. D., 
President of the United States 
Pharmacopoeial Convention. 

Notice — In order that the records may be brought 
up-to-date and checked, that card files may be pre- 
pared, and that the other functions of the Committee 
on Credentials may be performed, it is desirable 
that the Credentials of all Delegates appointed to 
attend this Decennial Meeting shall be in the hands 
of the Secretary, Mr. L. E. Warren, 2 Raymond St., 
Chevy Chase, Maryland, not later than March 15, 
1940. 



Buncombe County Medical Society 

At its first February meeting, held at the City 
Hall on February 5, the Buncombe County Medical 
Society heard the program which was scheduled for 
January 22 but was postponed because of a conflict. 
Dr. R. C. Bunts presented a paper on "Congenital 
Obstruction of the Bladder Neck", which was dis- 
cussed by Dr. W. C. Lott. On February 19 Dr. C. 
N. Burton gave a paper on "Panhysterectomy", 
with Dr. Julian A. Moore as respondent. 



Forsyth County Medical Society 

The February meeting of the Forsyth County 
Medical Society was held at the Smokehouse in Win- 
ston-Salem, on February 20 at 7 o'clock. The Guest 
Speaker was Dt. Howard Holt Bradshaw, Associate 
Professor of Surgery at the Jefferson Medical Col- 
lege, Philadelphia. Dr. Bradshaw, who has done a 
most impressive amount of Thoracic Surgery and is 
one of the outstanding men in that line in the 
country, spoke on "The Surgical Treatment of 
Bronchiectasis". His lecture was illustrated by 
lantern slides and motion picture:-;. A number of 
visitors from Stokes, Surry, Yadkin, and Guilford 
counti \s were present. 



Guilford County Medical Society 

The Guilford County Medical Society met on Feb- 
ruary 1 at the Jefferson Roof Garden in Greensboro. 
Guest speakers were Dr. T. W. M. Long, whose sub- 
ject was "Insurance as Offered to the Public", and 
Dr. Arthur Ambler, of A.sheville, who spoke on "The 
Present Status of Anesthesia". 



Halifax County Medical Society 

The Halifax County Medical Society held its regu- 
lar meeting on Friday night, February 9, at 7:00 
o'clock at the Roanoke Rapids HospitV.l, with Dr. 
White, president of the society, presiding. 

Dr. C. T. Smith, of Rocky Mount, presented a 
paper on "Diabetes and Diabetic Coma", in which 
the salient symptoms and the modern advances in 
treatment were discussed. 



Johnston County Medical Society 

The Johnston County Medical Society met in Ben- 
son on January 30 for a supper meeting. Drs. Mc- 
Bride and Persons, of Duke University, gave a talk 
on "The Uses and Misuses of Sulfanilamide and 
Sulfapyridine". and Dr. K. L. Johnson, a dentist, 
showed moving pictures in technicolor of the ex- 
traction of impacted teeth by using an instrument 
to break them before removal. 



Educational Qualifications of 
Health Officers 

The American Public Health Association has re- 
cently adopted for distribution a report on the "Edu- 
cational Qualifications of Health Officers", in the 
belief that it will serve a useful purpose in raising 
the educational standards of professional public 
health personnel. Copies may be secured without 
cost from the American Public Health Association, 
50 West 50th Street, New York, N. Y. 



News Notes 

Dr. J. E. McLaughlin, formerly of Statesville, an 
honorary fellow of the Medical Society of the State 
of North Carolina and of the Iredell-Alexander 
.Medic:'.! Society, is now living with his son-in-law 
and daughter. Dr. and Mrs. J. S. Talley, in Trout- 
man. Dr. McLaughlin retired from active practice 
in 1937 because of failing eyesight, after having 
practiced for fifty-one years. 



NORTH CAROLINA MEDICAL JOURNAL 



March, 11)40 



Oificers 

President: Mrs, C, F, Strosnider, Goldsboro. 

President-Elect: Mr.s, C, R, Hedrick, Lenoir, 

Chairman of Past Presidents: Mrs. P. P, McCain, 
Sanatorium, 

Corresponding Secretary: Mrs, Jack Harrell, Golds- 
boro, 

Recording Secretary: Mrs, J, D, Freeman, Wil- 
mington, 

Treasurer: Mrs, C, E, Judd, Raleigh, 



BEGINNING OF THE WOMAN'S 
AUXILIARY 

The Auxiliary to the Medical Society of 
the State of North Carolina has grown .so 
rapidly and the membership has varied so 
greatly in the seventeen years of its exist- 
ence that we felt it might be interesting to 
write a little about our beginnings and of 
those foundations upon which we have built. 

The seventieth annual session of the Medi- 
cal Society of the State of North Carolina 
was held in Asheville in April, 1923, with 
Dr, John Wesley Long presiding. In his 
President's Address, Dr, Long announced 
the birth of our Auxiliary on Sunday, March 
17, 1923, at Sanatorium, The Auxiliary was 
the brain child of Mrs, P. P, McCain, 
Daughter of a doctor and wife of a doctor, 
Sadie McBrayer McCain could not remember 
when she first attended an annual meeting 
of the State Medical Society, She had caught 
the vision of a group of wives and daughters 
who would meet together in an effort to 
"promote unity, harmony and concord be- 
tween the members of the medical profession 
and between the families of such members; 
to assist in the social activities at state, dis- 
trict and county society meetings; to in- 
terpret to the public the traditions, aims and 
ob,jects of the medical profession; to frater- 
nize with women's organizations of whatso- 
ever kind, and to promote in every possible 
way the interests in general of the medical 
profession — locally, and in the State and Na- 
tion," (See Constitution and By-Laws in the 
1923 Transactions of the Medical Society 



OF THE State of North Carolina,) Mrs, 
McCain's father, Dr. L, B, McBrayer, was 
secretary-treasurer of the Medical Society 
and deepl.v interested in his daughter's 
vision. Up to the day of his death Dr, Mc- 
Brayer maintained his interest in the Aux- 
iliary and its activities. He considered it an 
integral part of the Medical Society, Our 
program was always incorporated in the pro- 
gram of the Medical Society, Our member- 
ship list and proceedings always had a place 
in the Transactions, Dilatory presidents 
were gently and courteously prodded until 
the material was in. The Auxiliary is deep- 
ly indebted to Dr, McBrayer for his kindly 
consideration and his understanding friend- 
ship through many years. We feel that a 
great part of the credit for the formation of 
our Auxiliary belongs to Dr, McBrayer — 
that it was through his interest that Dr, 
Long became interested and took the .journey 
to Sanatorium to discuss it with Mrs, Mc- 
Cain, 

In Dr, Long's President's Address full 
credit was given to Mrs, McCain, and re- 
sponsibility for the "proper raising and edu- 
cation" of the baby auxiliary was placed 
upon her shoulders. He asked that the 
Society "acknowledge paternity and give its 
approval by resolution in the House of Dele- 
gates," This was done. 

On April 18, 1923, the Auxiliary was for- 
mally organized — or christened, as Dr, Long 
expressed it — at a meeting in Kenilworth 
Inn, Biltmore, with Mrs, McCain acting as 
organizing chairman. Dr. Long and Dr. Mc- 
Brayer attended the meeting and gave it 
official sanction, Mrs, C, S, Red, of Houston, 
Texas, President of the Auxiliary to the 
American Medical Association, was also 
present and gave a brief history and account 
of the work of the Auxiliary, Mrs, McCain 
was elected president and Mrs, I, W, Faison, 
of Charlotte, President-Elect, There were 
fifty-three wives of doctors present. 

In our article next month we shall attempt 
to tell something of our projects and of how 
well we have kept the faith with the Medical 
Society, 

Mrs, J, BUREN Sidbury, Chairman 
Public Relations, Auxiliary to the 
Medical Society of the State of 
North Carolina, 



March, 1940 



WOMAN'S AUXILIARY 



173 



AN EXAMINATION FOR MEMBERS OF 

THE AUXILIARY TO THE MEDICAL 

SOCIETY OF THE STATE OF 

NORTH CAROLINA 

Questions complied by Mrs. C. F. Stros- 
nider. 

Answers compiled by Mrs. P. P. McCain. 
Financial statements verified by Mrs. E. 
C. Judd. 

Request: Will each Auxiliary member 
please study these questions and answers? 
— Anna L. Strosnider, President. 

1. When was the Auxiliary formed? April 
18, 1923. 

A. Where? Asheville. How many mem- 
bers ? Fifty-three. 

P). Tell all you know about this meeting. 
On March 17, 1923, Dr. John Wesley 
Long, then president of the Medical 
Society of the State of North Caro- 
lina, went to Sanatorium to talk over 
with Mrs. P. P. McCain the organi- 
zation of an Auxiliary to the State 
Medical Society. As a result of this 
conference Mrs. C. S. Red, president 
of the Auxiliary to the American 
Medical Association, was present at 
the annual meeting in A.sheville. The 
Auxiliary was formally organized at 
this meeting, April 18, 1923, by Mrs. 
C. S. Red and a Constitution and By- 
Laws were adopted. Reference — 
Transactions of the Medical So- 
ciety OF THE State of North Caro- 
lina, 1923, pp. 466-467. 

2. Has the Auxiliary gained in members? 
Yes, from 53 in 1923 to 423 in 1938. 

3. What are the offices in the Auxiliary? 
President, three vice presidents, record- 
ing and corresponding secretaries, and 
treasurer. 

A. Who are the 1939-40 officers? See 
official stationery for 1939-40. 

B. Name the past presidents of the Aux- 
iliary. 

1923 — Mrs. P. P. McCain, organiza- 
tion president 

1924— Mrs. P. P. McCain, Sana- 
torium 

1925— Mrs. I. W. Faison, Charlotte 

1926— Mrs. J. Howell Way, Waynes- 
ville 



1927— Mrs. R. S. McGeachy, Kinston 
1928 — Mrs. J. B. Lawrence, Raleigh 
1929— Mrs. A. B. Holmes, Fairmont 
1930 — Mrs. J. H. Macon, Warrenton 
1931— Mrs. W. R. Murphv, Snow 

Hill 
1932— Mrs. R. S. McGeachy, Green- 
ville 
1933— Mrs. W. P. Knight, Greens- 
boro 
1934— Mrs. J. W. Huston, Asheville 
J. B. Sidbury, Wilming- 



1935- 



-Mr.s. 

ton 
1936— Mrs. C. P. Eldridge, Raleigh 
1937 — Mrs. J. R. Terry, Lexington 
1938— Mrs. W. T. Rainey, Fayette- 

ville 
1939— Mrs. J. A. Elliott, Charlotte 
1940— Mrs. C. F. Strosnider, Golds- 

boro. 

What are the duties of each officer? 
These given by Roberts Rules of Order. 

What are the objectives of the Auxil- 
iary? Reference — TRANSACTIONS, 1938, 
p. 635. Art. 11. Sec. 1. 

Section 1. Objects . . . "The objects 
of this organization shall be to in- 
terpret the aims of the medical pro- 
fession to other organizatons inter- 
ested in the promotion of health edu- 
cation : To assist in the entertain- 
ment at the meetings of the Medical 
Society of the State of North Caro- 
lina ; to promote friendliness among 
the families of the medical profes- 
sion ; and to do such work as may be 
approved from time to time by the 
Advisory Committee appointed by 
the Medical Society of the State of 
North Carolina." 
A. What is the relationship of the State 
Auxiliary to the National Auxiliary? 
We are affiliated with the National 
Auxiliary, cooperating with it in its 
programs and objectives, and paying 
twenty-five cents for each member of 
an organized Auxiliary. In return we 
get many valuable suggestions and 
pamphlets, and much i)ractical infor- 
mation. 
How do we become members of the 
Southern Medical Auxiliary? 



174 



NORTH CAROLINA ifEDICAL JOURNAL 



March, 1940 



A doctor's membership in the South- 
ern Medical Association automatical- 
ly makes his wife a member of the 
Auxiliary to the Southern Medical 
Association. 

A. What officers and chairmen do we 
have si^ecifically for the Southern 
Medical Auxiliary? 

(1) Councillor — appointed by presi- 
dent of the Southern Medical 
Auxiliary. 

(2) Jane Todd Crawford Memorial 
Chairmen. 

(3) Research Chairman. 

These chairmen have specific 
duties which can be learned 
from our information sheet.s. 

B. What benefits do we derive from the 
Southern Medical Auxiliary? 
Borrowing from their library and the 
privilege of attending their stimulat- 
ing meetings. 

6. History of McCain Bed. 

A. ^^^len undertaken? 1928. Mrs. R. S. 
McGeachy, president. 

Why? To have a definite objective 
for the Auxiliary. 

B. How much have we spent on the up- 
keep of the McCain bed? 
$4,851..S6 has been paid the North 
Carolina Sanatorium up to April 1. 
1939. 

C. Who has occupied the McCain bed 
and how long was each a guest of 
the bed? 

(1) Mary Odum (child) Red 
Springs — 4':; months. 

(2) Eleanor Stevens (doctor's 
daughter) Monroe — 6 months. 

(3) Daisy Andrews (child) Carr- 
boro — 12 months. 

(4) Mi.ss Ardis Jester (nurse) San- 
atorium — 18 months. 

(5) Dr. J. S. Johnson (physician) 
Cary — 11 months. 

(6) Sara Beam (girl) Bry.son City 
— 5 months. 

(7) Marie Lowe (girl) Asheboro — 
7 months. 

(8) Harry Stegall (boy) Oxford— 
5 months. 

(9) Bertie Teaguc (young lady) 
Marshall — 4 months. 

(10) Mr. L. S. Sawyer (young man) 
Columbia — 14 months. 



D. Give the history of the naming of 
the bed. Reference — Transactions 
19.35, p. 453. 

E. What amount has the Auxiliary .set 
as a goal to raise for the endowment 
of this bed? The amount of $10,000. 

F. How much of this amount has been 
rai.sed to date? By April 1, 1939. 
81.421.66 of this amount had been 
rai.sed. 

7. The Student Loan Fund. 

.A. When was this organized and why? 
This fund was created in May, 1930. 
:Mrs. W. B. Murphy, president, to 
help worthy and needy doctors' chil- 
dren in their junior and senior years 
at college or for special work. 

B. How many loans have been made and 
how many have benefited from same? 
Up to September, 1939, six loans 
were made to three different people. 

C. How much money do we have in this 
fund? The amount in the bank No- 
vember. 1939, was $619.79. 

D. What is the goal set for this fund? 
The goal is $10,000. 

8. What is the Jane Todd Crawford Me- 
morial Fund? This fund to be used to 
erect a memorial to Jane Todd Craw- 
ford. 

A. Give the outstanding details of Jane 
Todd Crawford's life. Reference — 
Transactions, year 1933. p. 522. 

9. How much does the Auxiliary get from 
a Hycicia subscription? The Auxiliary 

gets $1.25 from each subscription. 
A. How does the Auxiliary use this 
money? This money is placed in the 
McCain Bed Endowment Fund, 
in. What are the Auxiliary dues? $1.00. 
A. Tell how this dollar is u.sed. 50 cents 
goes to McCain Bed upkeep : 25 cents 
to American Medical Auxiliary; 25 
cents for the State Auxiliary ex- 
penses. 
11. What is Doctor's Day? Doctor's Day is 
a project of the Southern Medical Aux- 
iliary, inaugurated for the purpose of 
honoring our doctors, both living and 
dead. 

A. When? March 30. 

B. Why was this date chosen? This 
date was chosen because on this date 
anesthesia was first given to the 



March, 1940 



IN MEMORIAM 



175 



world. Reference — TRANSACTIONS, 
1935, p. 453. Executive Board Meet- 
ing Minute.s, number 5. 

12. Why should every doctor's wife belong 
to the Auxiliary? (1) To meet and dis- 
cuss medical problems that are pertinent 
to the doctor's wife; (2) To gain infor- 
mation for helping lay groups; (3) To 
learn to know other doctors' wives bet- 
ter. 

13. How can we make the Auxiliary more 
interesting and useful to its members? 

Have something definite to offer in 
the way of a program — short, spicy, 
but informative — at every meeting; 
encourage newest and oldest wives to 
attend; etc. 



3n mpmnrtam 



NOTICES 

Owing to illness Mrs. John C. Tayloe has 
had to resign as Councillor for the Second 
District. Mrs. Graham Ramsey, 320 College 
Avenue, Washington, has now assumed the 
duties of Councillor for the Second District. 
Anna L. Strosnider, Pres. 



The 18th Annual Convention of the Wom- 
an's Auxiliary to the American Medical As- 
sociation will be held in New York City, 
June 10-14, 1940, with headquarters in the 
Hotel Pennsylvania. In view of the fact that 
the second edition of the World's Fair will 
accelerate advance hotel reservations, it is 
urged that reservations be made immediate- 
ly through the Housing Bureau which has 
been set up by the American Medical Asso- 
ciation, namely Dr. Peter Irving, Room 1036, 
233 Broadway, New York City. 



Have you made your hotel reservation for 
the 18th Annual Convention of the Woman's 
Auxiliary to the American Medical Associa- 
tion which will be held in New York City, 
June 10 to 14. 1940? 

The headquarters are at the Hotel Penn- 
sylvania and we are sure you will not want 
to miss this convention which promises to be 
an outstanding one. MAIL YOUR RESER- 
VATION TODAY to Dr. Peter Irving, Hous- 
ing Bureau, Room 1036, 233 Broadwav, New 
York City. 



DR. JAMES ARTHUR KEIGER 

Di-. James Arthur Keiger of Greensboro, one of 
our outstanding and most beloved members, died 
Thursday morning, February 1, 1940. He had been 
in declining health for several months, and on Jan- 
uary 31 underwent an operation for gall stones, 
hoping to regain his health at least in part, but his 
physical condition was so depleted that he was un- 
able to rally from the shock of operation. 

Dr. Keiger was bom in Stokes County near King, 
a son of the late John W. Keiger and Mrs. Martha 
Schaub Keiger. After attending the public schools 
in Stokes County he was a student at Booneville 
high school, graduated from the University of North 
Carolina in 1909 with an A. B. degree, and then 
taught school in High Point for two years. 

He later took up the study of medicine and gradu- 
ated from the University of Virginia in 1914 with 
Phi Beta Kappa honors. He served his internship 
at Orange Memorial Hospital, Orange, N. J., and 
did post graduate work at Bellevue Hospital, New 
York. He was later commissioned as Captain in 
the U. S. Public Health Sei'vice and was stationed 
at Camp Greene, Charlotte, N. C, during the World 
War. 

He came to Greensboro in 1920 and opened offices 
for the practice of his profession, specializing in 
diseases of the genito-urinary tract and derma- 
tology; here he enjoyed a lucrative practice until 
his health so declined that he was forced to limit 
his time in his office and take needed rest in an 
effort to regain his health. 

Dr. Keiger was a member and past president of 
this Society, a member of the State Society and of 
the American Medical Association. 

Dr. Keiger was married to Miss Ethel Bollinger 
in 1922, and of this union one son, Jimmy, survives. 
Also surviving are his wife, four brothers, Charles 
E. Keiger of Statesville, M. F. Keiger of Tobacco- 
ville, Dr. 0. R. Keiger of Winston-Salem, and Dr. 
C. C. Keiger of Charlotte, and two sisters, Mrs. 
John Lee Wilson of Madison and Miss Blanche 
Keiger of Greensboro. 

Funeral services were held for Dr. Keiger in the 
First Presbyterian Church of Greensboro, services 
being conducted by Dr. Charles Myers, assisted by 
Dr. J. B. Craven, pastor of West Market Street 
Methodist Church, and intennent followed in Forest 
Lawn Cemetery. The funeral was attended by a 
large concourse of sorrowing friends and relatives. 

Dr. Keiger, a quiet unassuming man, but well 
qualified in his special branch of medicine, was held 
in high esteem not only by his patrons but by all 
who had the privilege of knowing him, and I dare 
say that no member of this Society was more be- 
loved by its members. He had no enemies, and his 
friends were limited only by the number of those 
who knew him. It is with a feeling of deep sorrow 
that we bow in humble submission to the Divine will 
in calling hence our beloved brother and co-worker, 
and we extend our sincere sympathy to his sorrow- 
ing familv and friends. 

C. W. Banner, 

Chairman Obituary Committee 

Guilford County Society. 



176 



NORTH CAROLINA MEDICAL JOURNAL 



March, 1940 



BOOK REVIEWS 



DISEASES OF THE GALLBLADDER AND BILE 
DUCTS. By Waltman Walters, B.S., M.D., M.S. in 
Surgery, Sc.D., F..\.C.S., Head of Section in Division 
of Surgery. The Mayo Clinic; Professor of Surgery, 
The Mayo Foundation (L^niversity of Minnesota); 
and Albert M. Snell, B.S., M.S. in Medicine, F..A..C.P., 
Head of Section in Division of Medicine, The Mayo 
Clinic; Professor of Medicine, The Mayo Foundation 
(University of Minnesota). 645 pages with 342 
illustrations on 195 figures. Philadelphia and Lon- 
don: W. B. Saunders Company, 194n Cloth $10.00. 

It is difficult to conceive of a more comprehensive 
and intelligently detailed presentation of diseases 
of the gallbladder and bile ducts than is put forth 
in the monograph by Walters and Snell. 

In this work the subjects are completely developed 
in a most interesting and orderly sequence from 
their early historical existence to our present day 
knowledge, covering most meticulously the anato- 
mical, phsyiological and pathological aspects as well 
as the medical and surgical treatment. 

One is impressed by the exhaustive study in com- 
piling this treatise and the delightful style of pre- 
sentation. It is a distinctly valuable contribution to 
medical literature. 



.\CCEPTED FOODS AND THEIR NUTRITION- 
AL SIGNIFICANCE, a publication of the Council 
on Foods of the .American Medical Association. 
Cloth, Price, $2.00 postpaid. Pp. 512; Chicago: 
American Medical Association, 1939. 

ACCEPTED FOODS AND THEIR NUTRITION- 
AL SIGNIFICANCE contains descriptions and de- 
tailed information regarding the chemical composi- 
tion of more than 3,800 accepted products, together 
with a discussion of the nutritional significance of 
each class of foods. The book provides also the 
Council's opinion on many topics in nutrition, die- 
tetics and the proper advertising of foods. 

This book will be a welcome reference book for 
all persons interested in securing authoritative in- 
formation about foods, especially the processed and 
fabricated foods which are widely advertised. The 
accepted products are classified in various categories; 
fats and oils; fi-uit juices including tomato juice; 
canned and dried fruit products; grain products; 
preparations used in the feeding of infants; meats, 
fish and sea foods; milk and milk products other 
than butter; foods for special dietetic purposes; 
sugars and syrups; vegetables and mushrooms; and 
unclassified and miscellaneous foods, including gela- 
tin, iodized salt, coffee, tea, chocolates, cocoa, choco- 
late flavored beverage bases, flavoring extracts, 
dessert products, baking powder, cream of tartai-, 
baking soda, cottonseed flour. There is a suitable 
subject index as well as an index of all the manu- 
facturers and distributors of food products that 
stand accepted by the Council on Foods. 

ACCEPTED FOODS is indispensable for the 
library of every physician concerned with foods and 
nutrition. 



INJECTION TREATMENT OF HERNIA, HY- 
DROCELE. GANGLION. HE>10RRHOIDS. PROS- 
T.\TE GLAND. ANGIOMA, VARICOCELE. VARI- 
COSE VEI.NS. BURSAE AND JOINTS. By Penn 
Riddle. B.S., M.D., F.A.C.S., .i^ssistant Professor of 
Clinical and Operative Surgery, Baylor University, 
College of Medicine; Director of the Vaiicose Vein 
Clinic, Parkland Hospital, Dallas, Texas. Cloth. 
Price, S5.50. Pp. 290, with 153 illustrations. Phila- 
delphia and London: W. B. Saunders Company. 
1940. 

This is an excellent detailed and complete work 
on treatment by injections. The author covers in 
detail the essential anatomy of the part, gives a 
brief history of the development of injections, and 
describes the actual technique of injection. 

He has evidently investigated the various types 
and methods of injections with an open mind, and 
clearly states what may be expected from each. 
Nowhere in his work does he claim any cure-all 
properties for any method. 

The text is most explicit and detailed, so that 
one needs little infoi-mation not included in the 
author's description to proceed with the various 
forms of injections. He is most particular to em- 
phasize that in many instances repeated injections 
over a period of time are necessary to obtain de- 
sired results, gi\ing the average length of time 
required. 

Beautiful, clear illustrations are profusely scat- 
tered throughout the text, making it very easy for 
the novice to understand the procedures. 

The work will be of help to any on? practicing 
the injection treatment, and to one who is not 
familiar with the injection treatment but who wis'nes 
to learn it, it will be invaluable. 



WHAT IT .MEANS TO BE .\ DOCTOR. By 

Dwight .Anderson. Price, cloth, Sl.OO; paper, 25 
cents. Pp. 87. New York: Medical Society of the 
State of New York, 1939. 

While Mr. Anderson is not himself a doctor, few 
writers have told more truly what it means to be 
a doctor of the highest type — loyal to his profes- 
sion, to his ideals, and to his patients. In nan-ative 
form, a doctor is followed through college, medical 
school, internship, into private practice and into the 
inner circles of organized medicine. No doctor could 
read it without having greater respect for his pro- 
fession; no layman, without greater admiration for 
his doctor. 



The Dominating Impulse in the Study of Medi- 
cine. — To those who, as teachers, watch successive 
classes of medical students progress in their course 
of study it is' always striking to see how each group 
responds with enthusiasm when, after a year or two 
of laboratory study, it reaches the stage where con- 
tact with patients begins. This is what they have 
been working toward and waiting for. Dissecting 
room, microscope, chemical experiment — these were 
but means to prepare them for the great end which 
is the human relationship between the physician and 
the patient. It is the desire for this human rela- 
tionship, with its opportunity for sympathetic in- 
timacy and altruistic service, that remains today, 
as it has' been through all the generations, the 
dominating impul.se in drawing men to the study of 
medicine. — Peabody. Francis W.: Doctor and Pa- 
tient, New York. 'The Macmillan Company, 1939. 



Anril. 194(1 



ADVERTISEMENTS 



III 




New Waterless Metabolar 

• • • Dy • • • 

McKESSON 

Some of the many features incorporated in the 
new McKesson Waterless Metabolorr 

Guaranteed bellows — safety valve on bellows — 
strip chart — soda lime indicator — dial thermometer 
— built-in barometer — visible check valves — all 
moving parts on ball bearings — easy computation 
— all porcelain and chrome finish. 

Price complete without stand $225*00 
Price complete with stand $255«00 

Ask our representative for demonstration and literature. 

WINCHESTER 

"CAROLINA'S HOUSE OF SERVICE" 

Winchester Surgical Supply Co. Winchester-Ritch Surgical Co. 



106 East 7th Street 



Charlotte, N. C. 



Ill North Greene Street Greensboro, N. C. 



STUART CIRCLE HOSPITAL 



RICHMOND, VIRGINIA 

Medicine: 

Alexander G. Brown, Jr., M. D. 
Osborne O. .\shworth, M. D. 
Manfred Call. Ill, M. D. 
M. MoiTis Pinckney, M. D. 
Alexander G. Brown, III, M. D. 



Surgery: 

Charles R. Robins, M. D. 
Stuart N. Michaux, M. D. 
Robert C. Bryan, M. D. 
A. Stephen.^ Graham, M. D, 
Charles R. Robins, Jr., M. D. 



Obstetrics: 

Greer Baughnian, M. D. 
Ben H. Gray. M. D. 
Wm. Durwood Sugps, M. D. 
Spotswood Robins, M. D. 

Ophthalmology. Otolarvngologv: 

Clifton M. Miller, M. D. 
R. H. Wright. M. D. 
W. L. Mason, M. D. 

Pediatrics: 

Algie .S. Hurt, M. D. 

Chas. Preston Manpuni, M. D. 

Physiotherapy: 

Elsa Lange, B. S., Technician 
Margaret Corbin, B. S., Tech- 



Urological Surgery: 

Joseph F. Geisingcr, M. D. 
Frank Pole, M. D. 

Oral Surgery: 

Guy R. Harrison, D. D. S. 

Pathology: 

Regena Beck, M. D. 

Roentgenology and Radiology: 

Fred M. Hodges, M. D. 
L. O. Snead, M. D. 
R. A. Berger, M.D. 

Medical Illustrator: 
Dorothy Booth 



.Stuart Circle Hospital has been operated twenty-six years, affording scientific care to 
patients in General Medicine. Surgery. Obstetrics and the various medical and surgical 
specialties. Detailed information furnished physicians. 

CHARLOTTE PFEIFFER, R. N., Superintendent. 



IV 



CONTENTS 



April, 1940 



North Carolina Medical Journal 

Official Organ of 
The Medical Society of the State of North Carolina 



VOLDME 1 
NUMBEB 4 



April, 1940 



9s. 00 A YEAR 
88 CENTS A COPY 



contents 



Originai, Artules 

The Application of Medical Science to the Indi- 
vidual — G. Canby Robinson, M.D. - - - - 177 

Carcinoma of the Bronchus: Some Findings in 
Twenty Cases — James A. Harrill, M.D. - - 180 

Metvazol in the Treatment of Mental Disease 
and a Report on its Use at the State Hospital 
— R. H. Long, M.D. 184 

The Diagnosis and Treatment of the Anemias 
—Robert P. Morehead, M.D. 187 

The Mental Hygiene of Childhood in the Public 
Health Program— Raymond S. Crispell, M.D. 100 

The Newer Knowledge of Vitamins — Victoria 
Carlsson ----- IflS 

Diabetic Coma— Paul F. Whitakcr, M.D., and 
Kilby P. Turrentine, M.D. 201 

Pi'ophylactic Measures of Proven Value in 
Some of the Infectious Diseases — J. Buren 
Sidbury, M.D. 204 

Distribution of Syphilis Among the Patients in 
Pediatrics and Obstetrical Practice — D. E. 
Robinson, M.D., W. B. Perry, M.D., H. R. 
Germer, M.D., G. M. Leiby, M.D. - - - - 208 

The Place of Education and Public Health in 
Cancer Control — C. C. Carpenter, M.D., and 
R. P. Morehead, M.D. -------- 210 

Editorials 

The Eighty-Seventh Annual Meeting - - - 212 
"Now is the Time for -All Good Men—" - - 212 
Reply to Dr. Schaffle 213 



Case Reports 

Solitary Intracranial Tuberculoma in an Adult 
F. T. Harper, M.D. 214 

Duke Hospital Clinico-Pathological Conference 216 

Phenol Gangrene Complicating Diabetes Mel- 
litus— Verne S. Caviness, M.D. - - - - 2111 

Correspondence 

Letter from Dr. Karl Schaffle ----- 222 
Statement from Dr. W. Z. Bradford - - - 222 

Bi'LLETiN Board 

President's Message -------- 223 

Notes from the Secretary's Office - - - ■ 223 

News Notes from Duke University School of 
Medicine and Duke Hospital 223 

Notes from the University of North Carolina 
School of Medicine --------- 224 

News Notes from the Wake Forest Medical 
School - 224 

News Notes from the State Board of Health - 224 

North Carolina Conference for Social Service 225 

Mecklenburg Tuberculosis Sanatorium - - - 225 

County Societies - 225 

News Notes - - - 225 



Wo.MAN's AL•.\ILI.\R^ 
Organization, 1938-.39 

Book. Hi mews 

227 



226 



Entered as yeroiKU-Iiiss matter January *J. 1940. at the Pnst Office al Wiiiston-Salem. Xiirth Carolina, under the Act of Au^st 
24, I9i;. Copyright 1910 by ttie Medical Society of ttie Slate of North Carolina. 



North Carolina Medical Journal 

Owned and Published by 
The Medical Society of the State of North Carolina 



Vol. 1 



April, 1940 



No. 4 



THE APPLICATION OF MEDICAL SCIENCE TO THE INDIVIDUAL 

G. Canby Robinson, M. D. 

Associate Physician and Director of 
Medical Clinics 

Johns Hopkins Hospital 
Baltimore 



Many years ago I read somewhere a brief 
description of medicine attributed to Mar- 
chand, an eminent teacher of the old and 
glorious German school of medicine. His 
words impressed me deeply, and fortunately 
I wrote them down. I say fortunately, be- 
cause I have no trace of where I saw them, 
or who translated them from the German, 
and they remain like the memory of a kindly 
and gracious act done by some passing 
stranger in a crowded street. These words 
I have kept before me through the more 
mature years of my medical career, and have 
weighed their value against the teachings of 
experience. I have quoted them on former 
occasions to express a medical ideal, but to- 
day I repeat them not as an ideal, but be- 
cause of the conviction that they briefly ex- 
press the essence of medical service. It is 
with these words of Marchand as a text that 
I wish to discuss the application of medical 
science to the individual. They are as fol- 
lows: 

"Seek truth. Discover causes. Learn how 
they disturb life and how order is reestab- 
lished. By science and persuasion preserve 
men. By science, gentleness and firmness 
combat death and reduce suffering. Guide, 
encourage and console in a brotherly and 
tolerant spirit. This is medicine." 

In these few words equal consideration is 
given to the science and to the art of medi- 
cine. The essence of medical science is ex- 
pressed in the first three phrases: "Seek 
truth. Discover causes. Learn how they dis- 
turb life and how order is reestablished." 
It is clear that these principles of science 

Address delivered at the dedication of the new Medical and 
Public Hea'tli Bui'ding of the University nf North Carolina at 
the Sesqui-Centennial Celebration, December 4, 1939. 



are meant to be applied not to the study of 
a reaction in a test-tube, or to a phenome- 
non that can be observed only in the labora- 
tory. They are meant to be applied to the 
study of the sick human being by the doctor 
using any means that will reveal truth, that 
will discover causes and that will teach him 
to understand disturbances of function and 
of structure, and give him knowledge of how 
to bring life back as far as it may be done, 
into a state of vital harmony which we think 
of as health. These few words could be 
readily expanded to stretch before us a wide 
view of the disciplines that constitute much 
of the medical curriculum of our schools. 

We cannot learn how life is disturbed and 
how order is reestablished without a knowl- 
edge of normal, healthy man, as revealed to 
us bit by bit in the study of anatomy, physi- 
ology and biochemistry. We cannot discover 
causes without some knowledge of patho- 
genic micro-organisms, pathological pro- 
cesses and derangements of functions. Nor 
can we learn how order is reestablished 
without a ground-work of pharmacology and 
surgical procedures. We must learn to seek 
truth as related to the human body and mind 
by special forms of searching. The trained 
eye, the listening ear, the sensitive finger 
guided by the mind that is prepared are 
essential for success in seeking the sort of 
truth that is required. Technical proficiency 
in the use of methods and instruments and 
the ability to discern the essential from the 
insignificant all play a part in seeking truth 
regarding the human organism. We as doc- 
tors have before us the most intricate and 
confusing tasks of science, but at the same 
time, the most interesting, fascinating and 



178 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



varying problems that man is called upon to 
study. Let your own imaginations sweep 
across the multitude of situations in the 
realm of medicine and you will need no 
further enumeration to convince you that 
the tenets of science are the only safe guide 
to the solution of the problems that modern 
medicine has to face. It is no wonder that 
specialism is inevitable, and that many 
hands and many minds are now required to 
perform the tasks attempted by a single pair 
of hands and a single mind in years gone by. 
It is no wonder that hospitals are necessary, 
when team-work, consultation and technical 
proficiency are needed to meet the demands 
of present-day medical science on serious oc- 
casions when life or chronic illness may be 
in the balance. 

But there is more to medicine than science. 
There is the human relation between doctor 
and patient. It is not by a cold and calcu- 
lated process that medical science can be 
applied to the needs of the individual. There 
are many variations in the conditions and 
situations of human beings, obviously de- 
termined by age, sex and race, and less ob- 
viously by constitution and personal charac- 
teristics, by inheritance, childhood experi- 
ences, education, economic status and many 
other factors. It is these variations that led 
the philosopher John Dewey to write, "Just 
in the degree in which a ph.vsician is an 
artist in his work he uses his science, no 
matter how extensive and accurate, to fur- 
nish him with tools of inquiry into the in- 
dividual case, and with methods of forecast- 
ing a method of dealing with it. Just in the 
degree in which, no matter how great his 
learning, he subordinates the individual case 
to some classification of disease and some 
generic rule of treatment, he sinks to the 
level of the routine mechanic. His intelli- 
gence and his action become rigid, dogmatic, 
instead of free and flexible." 

Sauerbruck expresses somewhat the same 
idea from another viewpoint when he writes, 
"Physiology, chemistry and biology are use- 
ful aids in the search for medical truth, but 
will not of themselves, alone or together, ex- 
plain the obscure system of events that con- 
stitutes the entity of human disease." Thus 
an eminent philosopher recognizes the neces- 
sity of individualizing medical .service if we 
are not to sink to the level of the routine 
mechanic, and a leader in surgery tells us 
that the fundamental sciences are not enough 



to explain the obscurities of human illness. 
Medical service requires more than science 
as it is defined and understood today. 

Let us return to Marchand for the answer 
to the question as to what more is needed. 
At first he clings to science but adds per- 
suasion as a means of preserving men. "By 
science and persuasion preserve men." He 
recognizes that science alone is not enough 
in seeking that broad and all-inclusive ob- 
jective, "preserve men", but that the reaction 
of one person to the persuasion of the other 
must be added. He then tells us how per- 
suasion should be carried on, but still science 
precedes. "By science, gentleness and firm- 
ness combat death and reduce suffering." 
Here the emphasis is shifted from the gen- 
eral to the specific and he calls upon us to use 
gentleness and firmness in performing the 
tasks required to combat death and to reduce 
suffering, and bids us to combine these at- 
tributes of behavior with science in the study 
and care of the patient who is in danger and 
who suffers. 

Marchand then lays down very simply and 
directly the guiding principles for the atti- 
tude of the doctor toward his patient in 
these words, "Guide, encourage and console 
in a brotherly and tolerant spirit." Here he 
tells us not only what we should strive to do 
in order to make our service and ministra- 
tions of the greatest value, but also the spirit 
in which it should be done. A brotherly 
spirit is that of equality, as there is no other 
human relationship where so many factors 
of inheritance and of possession exist in 
common as in the relationship of brothers. 
A tolerant spirit is that which is as free as 
possible from judgment of the conduct of 
another. "Judge not, that ye be not judged" 
expresses an attitude that should always 
exist in the personal doctor-patient relation- 
ship, and unless it does exist, efforts to guide, 
encourage and console may go for naught. 

Finally, after the science of medicine as 
the primary requirement of medical service 
has been combined with the functions of the 
physician toward the individual and the 
spirit of medical .service has been described, 
Marchand exclaims, "This is medicine." The 
longer I have pondered over this description 
of medicine, the more firmly have I become 
convinced that this final phrase is true and 
justified. 

There are some practical lessons in this 
concept that we have examined, and my own 



April, 1940 



APPLICATION OF MEDICAL SCIENCE— ROBINSON 



179 



studies of hospital patients have demon- 
strated conclusively that even under condi- 
tions most favorable for the application of 
science in the study of disease, there are ele- 
ments of illness that require the study of the 
patient as a person or, in other words, as an 
individual with a definite place in society 
and with a conception of how he should live 
and behave in his own particular social situ- 
ation. Because the patient is ill, his social 
status is disturbed, and it is with the hope 
of being restored to his normal life that he 
seeks medical aid. Disease, it is found, is 
only one factor of illness which prevents a 
normal way of living in a large majority of 
patients admitted to the medical service of 
the Johns Hopkins Hospital. Fear, worry, 
emotional tension and sometimes hate, also 
play a part in causing physical disability and 
suffering. 

Let us take for example a specific study'", 
an unselected series of fifty patients com- 
ing to the medical dispensary for digestive 
symptoms. As indigestion, to use the popu- 
lar name, is notoriously prone to occur with 
emotional disturbances, this example cannot 
be generally applied to other types of illness, 
but in this series of patients 76 per cent 
had .symptoms referable to emotional strain. 
There were 31 patients, or 62 per cent, in 
whom no evidence of di.sease could be found 
to account for their symptoms, and in 27 
of them, or in more than half the number 
studied, just plain worry, although often ex- 
cessive, was the cause of illness. 

This study was made by inviting the pa- 
tients, after their physical status had been 
determined, to sit quietly in a little oflice 
where they were encouraged to talk about 
their situations, their work, their families 
and their worries. What they said was re- 
corded in detail, and when put together with 
the usual clinical record, gave us material 
for the study of the patient as a whole. 

Among this group of patients rei^resent- 
ing a fair sample of those with dige.stive 
symptoms, there were several men with good 
indu.strial records overtaken by advancing 
years and by the insecurity involved in their 
situations. There was a young wife who.se 
family doctor told her she had a mild ca.se 
of gastric ulcer, and whose friends told her 
that this was an incurable disease. A thirty- 
one year old Polish housewife, with a Por- 

1. The studies referred to in tlie address were supporti'd in 
part by grants from Hie Josiaii Maey. Jr. Fnuiniatinn ami 
from tlic Joltn and Marj' R. Marltle Foundation. 



tugese husband, had been ill for two years 
because her husband and her father, whom 
her husband supported, were constantly in 
disagreement. A farm worker's wife of 
thirty-six had suflfered both in mind and 
body for three years, ever since listening to 
a radio health talk in which the early 
.symptoms of cancer of the stomach had been 
described. Her abdominal pain had been 
constant for a year, and she had made all 
her funeral arrangements before coming to 
the hospital, in spite of the fact that careful 
examinations failed to reveal any evidence 
of disea.se. For three years this patient had 
never failed to listen to the weekly I'adio talk 
which had initially precipitated her illness. 

The story of a young married baker of 
twenty is especially striking as an example 
of how worry may be a cause of illne-ss, how 
it may disturb life, and how order may be 
reestablished. After a fruitless search for an 
organic basis of mo.st distressing choking 
spells, weakness, and shortness of breath 
which brought this young man, he thought, 
near to death, he reluctantly confessed to a 
fear of tuberculosis. His symptoms had be- 
gun at the time of his marriage seventeen 
months before he came to the hospital and 
had increased in severity as his wife ap- 
proached the time when her first baby was 
expected, a few weeks later. He finally told 
the story which explained his anxiety. An 
older friend who lived next door was found 
to have tuberculosis at the time of his mar- 
riage, and died six months after his first 
child was born. The patient thought the 
same fate was in store for him, especially 
as his mother had repeatedly warned that 
he might have contracted the di.sease from 
his friend, and that his wife might have it. 
She even went so far as to say that he would 
probably die of it if he did not .stop playing 
the saxophone and staying up late at night 
to play with an orchestra. Assurance, a lec- 
ture to the mother, and the arrival of a fine 
son effected a speedy cure in this case. 

All the patients that have been mentioned 
recovered completely and remained well dur- 
ing succeeding months as long &?. they were 
followed, and the .same may be said for near- 
ly all of the twenty-seven patients in whom 
worry was the cause of illness. Their prob- 
lems were brought out into the light and 
their symptoms explained by combining in 
hospital practice the efforts of the specialist 
with the traditional methods of the family 



180 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



physician. In many instances the function 
of the physician to guide, encourage, and 
console in a brotherly and tolerant spirit, 
had most to do in solving the problems of 
these patients. 

The mind as well as the body must be 
studied in an effort to discover causes, and 
even when the presence of organic disease 
has been established, the emotional disturb- 
ances can by no means be overlooked as a 
possible cause in making up the total picture 
of illness. In fact, there are certain diseases 
that usually have their accompanying emo- 
tional strain which cannot be overlooked if 
medical service is to be skilful, adequate and 
satisfying to the patient. 

Let us close then with the thought that the 
art of medicine is the application of medical 
science to the needs of the individual, and 
that in order to combine the art and the 
science of medicine, much study and thought 
must be given to the sick or injured patient 
as a person, to be treated as an individual 
problem. 



CARCINOMA OF THE BRONCHUS 
Some Findinc/s in Twenty Cases* 

James A. Harrill, M. D. 

Winston-Salem 

Bronchogenic carcinoma is a common con- 
dition, and appears to be increasing. Text- 
books of a decade ago stated that it consti- 
tuted about 1 per cent of all carcinomas, 
while today it comprises at least 10-12 per 
cent of all cancers'". It is found with the 
greatest frequency in the so-called cancer 
age, and is more frequent in males than in 
females. In this series 17 patients were 
males; 3, females — a ratio of 5.7:1. The 
average age was fifty-seven. The oldest pa- 
tient was sixty-eight; the youngest, forty- 
two. Six were in the fourth decade, 5 in the 
fifth and 9 in the sixth. All 20 belonged to 
the white race. 

There is no accurate knowledge of the 
etiology of bronchogenic carcinoma, although 
there seems, to be a definite relation.ship be- 
tween it and pre-existing inflammation in 



•From titc inriT rpcords of the Broiichoscopic rlinif. Kinc-J 
roiinly Hosnitnl. Drooklyn. New York. The author wislips tn 
th.ink Dr. M. C. Myrr,=r>n. Director of ttic nronfttoscopic rlinif. 
for tiis permission to us.- llu'-sr cases in tliis report. 

Head lieffire til-' Section on tiic l»racttce of Medicine. Medical 
."^oeiete of tile State cf North Carolina. Bcrnuida Cruise. May 
IS. I9.1». 
1. C'erf. I.. It.: Carclnom.-i ot tile Hruiiclius. Radiology L'S : 
t«s (April) IftlT. 




Fig:, la. The above photomicrograph sho\ys a ter- 
minal bronchiole with surroundinR loose connective 
tissue. The epithelium is of the simple columnar 
ciliated type >vith the nuclei at one level. At the 
base of the cilia there is a dark border line formed 
by the basal corpuscles of the cilia. Between the 
columnar cells on the right and on the left, active 
goblet cells may be seen. In these areas there is a 
break in the outline of the columnar cells. 




Fig. lb. The above photomicrograph is made from 
a section of the upper trachea, and shows the strati- 
fied columnar cells with cilia. In one or two areas 
the cilia are indistinct where the goblet cells break 
through to the free surface at the base of cilia. 
The nuclei are at all levels, with an even, orderly 
row of cylindrical nuclei forming the basal layer, 
beneath which there is a thin basement membrane 
(Bowman's membrane). The epithelium shows no 
variation from the normal. 



April, 1940 



CARCINOMA OF THE BRONCHUS— HARRILL 



181 



the lower respiratory tract'-'. A family his- 
tory of cancer was obtained in one case. 

Histologically the bronchial mucosa con- 
sists of a layer of ciliated columnar cells 
resting on a basal cell layer of ovoid cells. 
Deep beneath the basal cell layer lies the 
sub-mucosal tissue, consisting of areolar, 
fibrous and elastic tissue, and containing 
numerous mucous glands. (Fig. 1.) 

In the presence of chronic inflammatory 
processes in the bronchi, the ciliated colum- 
nar epithelium is often found to change to 
squamous-celled epithelium. Ormerod'^' has 
demonstrated the change from one type to 
the other in a single field. Fried'^' considers 
the basal cell layer responsible for the re- 
generative processes. The pathology of these 
tumors has been of interest to pathologists 
for many years, but they have not agreed 
upon which of the first two layers is re- 
sponsible for the formation of squamous- 
celled carcinoma. The adenocarcinomas 
probably arise in the mucous glands of the 
submucosal layer. Halpert''" states that all 
bronchogenic carcinomas arise from the "re- 
serve cells" of the basal cell layer by atypi- 
cal proliferation. 

The macroscopic appearance of the tumors 
in 19 cases could be classified as fungating. 
submucous and polypoid. Twelve presented 
themselves as fungating, friable masses ; five 
as submucous growths ; two as polypoid ; and 
the twentieth in the series was undetermined. 

As to location, the distribution was fairly 
even. Eleven were located on the right side 
and nine on the left. Seventeen were located 
in the main bronchi and were visualized by 
bronchoscopy. The remaining three origi- 
nated in a peripheral bronchus. (Fig. 2.) 

The local pulmonary and general .symp- 
toms, by them.selves, are not diagnostic. 
When cough, with or without sputum, he- 
moptysis and dyspnea, occurs for the first 
time in an individual of the cancer age, es- 
pecially when as.sociated with pain, carci- 
noma of the lung should be highly considered. 

Cough of duration from one month to ten 
years was present in 18 (90 per cent) of the 
cases, and was found to be the most constant 
symptom. It was productive in 13 cases (70 
per cent). 

■-'. Millpr. J, A., in Musser, J. H: Internal Medicine. Phila- 
delphia. Lea and Febiger. 1932, p. 616. 

;!. Ormerod. F. C: The Pathology and Treatment uf Car- 
einoina of the Bronchus. J. Laryng, and Otol. jj:733 
(Nov.) l!t:)7. 

1. Fried. U, M,: Primary Carcinoma of the Lungr. Baltimore, 
Williams and Wilkins'. 1932, p. 40, 

J. Halpert, B., cited by Ochsner and DeBakey (9). 



L.L.L. 




Fig. 2. Di.stribution according to the side involved 
and the area from which biopsy was taken. 

The second most prominent symptom was 
chest pain. This occurred in 14 (70 per 
cent) of the cases. Pain due to carcinoma 
of the lung is found to be more continuous 
than that due to any other intrathoracic con- 
dition, with the possible exception of aortic 
aneurysm. It has been said that its persist- 
ency and intensity almost puts it in a class 
by it.self. The pain in 9 cases was referred 
to the side of the lesion. In 2 cases it was 
referred to both sides of the chest. In the 
remaining 3 cases, the historian only men- 
tioned that pain in the chest was present. 
In 2 cases chest pain was the only pulmonary 
symptom. 

Hemoptysis was present in 10 cases (50 
per cent), ranging in duration from one 
month to six years. It is interesting to 
speculate as to the possibility of a benign 
adenoma undergoing malignant changes in 
the bronchus of the patient who had hemop- 
tysis for six years. 

Dyspnea was present in 4 cases (20 per 
cent), and occurred late in the course of the 
disease. 

Of the general symptoms, loss of weight, 
weakness, and night sweats, in the order 
mentioned, were the most prominent. Only 
in few of the cases did the general symptoms 
cause the patient to seek hospitalization. 

Other than thoracic pain, symptoms sug- 
gestive of metastasis to the ribs were present 
in 2 cases, to the cervical vertebrae in 1, to 
the thoracic vertebrae in 1, to the head of 



182 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



the femur in 1. to the pelvis in 2, and to the 
brain in 1. 

In these cases the recorded physical find- 
ings, together with the history, suggested 
the presence of carcinoma, tuberculosis, 
bronchiectasis, empyema or pneumonia. 

No physical signs are pathognomonic of 
this disease, and cancer is capable, depend- 
ing upon its size and location, of imitating 
any disease found within the chest. The 
most common condition with which it is con- 
fused is tuberculosis. Twenty-five per cent 
of the cases in this series were clinically 
diagnosed as tuberculosis. This is easy to 
understand when we stop to consider that 
these two conditions have symptoms, signs 
and roentgenographic appearances in com- 
mon. Roentgenographic appearances that 
occur in tuberculosis and are not seen in un- 
treated cancer are fibrosis and calcification : 
yet it must be remembered that both di-seases 
may be present in the same patient and that 
one positive sputum is at times misleading. 
One positive sputum may be a laboratory 
error, or the neoplasm may invade an old 
tuberculous encapsulated focus and liberate 
a few bacilli. Repeated search for the pres- 
ence or absence of tubercle bacilli is most 
important. The diagnosis of tuberculosis as 
final on one positive sputum with roentgeno- 
graphic findings of atelectasis, consolidation, 
cavitation or nodulation may deprive a can- 
cer patient of his chance for recovery. Two 
of the patients in this series had one posi- 
tive sputum. 

In reviewing 1286 autopsy reports at Sea 
View Hospital. Schwartz and Auerback"'' 
found that thirty-two patients sent to the 
hospital as cases of advanced pulmonary 
tuberculosis were found to have non-tuber- 
culous pulmonary disease without any evi- 
dence of tuberculosis. Sixteen, or 50 per cent 
of these cases, were classified as broncho- 
genic carcinoma. In 12 (75 per cent) the 
new growth occurred in the large bronchi. 
Anatomic review of the gro.ss pathological 
reports indicate that in 9 cases (75 per cent) 
the growths were within reach of the bron- 
choscope. 

An example of the difficulties of diagnosis 
is found in one of the first reported ca.ses. 
by Graves'"', one hundred years ago. Since 

f. S In*.-!!!!. S. an«l .\uert>ack. O.; Non-Tiil»«T'-ti'nii.i I'lil- 
mimarj' Disea>* Simulatins riilmonalT Tubcnnilosis. Sea 
V'-r Hnspital Ouarlcrl) Bulletin, vol. ). iii>. I (Oct.) 
193H. 

7. firates. R. J.: A System of Clinical Medicine. Dublin. 
Fannin and Co.. Iti43, p. TftS. 



his time the history, course of the disease, 
and physical findings have remained the 
same, but several important diagnostic aids 
have been added. These procedures which 
do not require meta.stasis before they can be 
used are : 

( 1 ) Roentgen-ray picture and fluoroscopic 
examination. 

(2) Bronchoscopic examination and bi- 
opsy. 

(3) Lung puncture. 

(4) Jlicroscopic examination of biopsy 
and lung puncture specimens. 

The fluoroscopic examination and roent- 
gen-ray pictures are of great value and 
should be the first step toward a positive 
diagnosis. The fluoroscope is of help in re- 
vealing bronchial ball valve block and in 
diflferentiating between mediastinal and lung 
neoplasms. Serial roentgenography is of 
much more value than a single film. 

Varied pictures are obtained, depending 
upon the size and location of the neoplasm, 
and they may be similar to those seen in 
other lung conditions. Lobar consolidations 
may be produced by tuberculosis, pneumonia, 
abscess, and cancer. Cavities may be pro- 
duced by abscess, tuberculosis, bronchiecta- 
sis, cancer, and gangrene. Miliary deposits 
may be caused by tuberculosis, cancer, bron- 
cho-pneumonia or pneumoconiosis. Large no- 
dules are formed by neoplasm, tuberculosis 
or silicosis. Atelectasis may be .secondary 
to tuberculosis, cancer, bronchiectasis, endo- 
bronchial neoplasm or foreign body. Fibro- 
sis and calcification are not seen in cancer, 
although fibrosis may be present in those 
cases which have received x-ray or radium 
therapy. 

In this series, from the x-ray findings, 16 
cases were diagno.sed as new growths. 2 as 
inflammatory, and in 2 the diagnosis was de- 
ferred. JIasses were seen in 8. atelectasis in 
9. pneumonic consolidation in 1. and pleural 
effusion in 3. X-ray evidence of metastasis 
was present in 5 cases. 

Bronchoscopy with biop.sy is the only 
method that we possess to make a positive 
diagnosis early. In 70-85 per cent of cases 
a positive diagnosis can be made by broncho- 
scopy and biopsy. 

These tumors present a varied broncho- 
.scopic appearance. In the majority of the 
cases, tumor tissue is encountered. In others, 
where the lesion is submucosal, the bronchus 



Apiil, liMll 



CARCINOMA OF THE BRONCHUS— HARRILL 



183 



is narrowed, the mucosa thickened and in- 
flamed, and evidence of mediastinal involve- 
ment may be present or absent. In those 
cases where the tumor is beyond a third 
order bronchus, the bronchoscopic picture 
may be normal or evidence of mediastinal 
involvement may be present, varying from 
encroachment of lumen by metastatic hilar 
lymph nodes to widened, thickened, and in- 
filtrated carina or a "frozen" tracheo-bron- 
cial tree. 

Tumor masses were seen in 10 cases. In 
5, the growth was submucosal. In 2, friable, 
polypoid masses were seen. In 17 of the 
cases, positive biopsies were obtained by 
bronchoscopy. In the remaining 3 ca.ses. 
one presented purulent secretions coming 
from the right upper lobe bronchus; another 
showed post-irradiation changes in the bron- 
chial muco.sa ( X-ray therapy had been given 
in another hospital) ; in the third case, the 
tracheo-bronchial tree was normal and a 
lobectomy was jierformed. Bronchoscopy was 
repeated in 4 cases — 3 for a second biopsy, 
and the fourth for broncho-scopic observa- 
tions following five months of x-ray therapy. 

While bronchoscopy does not determine 
the extent of the lesion, it definitely aids in 
establishing a diagnosis and assists the 
thoracic surgeon in selecting the cases which 
are best suited for operation. 

Aspiration biopsies were not made on 
these patients. Binkley"" reports 60 per cent 
positive biopsies in 56 cases. There are 
usually no harmful after-effects, and this pro- 
cedure should be used more often if the 
pathologist is capable and willing to commit 
himself on the basis of a few cells. 

The value of pathological examination of 
biop.sy and lung puncture specimens needs 
no discu.ssion. 

In three eases pleural effusions were pres- 
ent, and in one cancer cells were demon- 
strated by the ]Mandelbaum method. 

Exploratory thoracotomy is a valuable 
method of establishing a diagnosis and of 
determining whether operative removal of 
the tumor is possible and justifiable. 

It is unfortunate that, owing to a late ar- 
rival at a positive diagnosis, treatment mu.st 
often be directed toward relief of symptoms. 
Five patients received x-ray therapy, and 
these patients lived an average of two 
months longer than tho.se who did not re- 
ceive this form of treatment. One patient 

H. Binkk-v, J. S., filed by Ochsner and DeBakey (9). 



lived five months after receiving x-ray 
therapy. One ca.se was suitable for opera- 
tion, and expired eight days after lobectomy. 

The question of what type of treatment to 
use after a diagnosis has been made is im- 
portant. Because of the recent advancements 
and lowered mortality in thoracic surgery, 
surgery is the treatment of choice in those 
ca.ses where the growth, from the endoscopic 
point of view, is located in such a position 
that a lobectomy or pneumonectomy will re- 
move it, if the physical condition of the 
patient will permit either of these pro- 
cedures. 

To date there are 88 reported cases of 
total pneumonectomy for neoplastic disease. 
Of the 88 cases 56 (63.6 per cent) died, and 
32 (36.4 per cent) recovered. Of the patients 
who recovered, five subsequently died of 
metastasis or from other causes''". 

Other methods of treatment are : 

(1) Irradiation therapy. 

(2) Bronchoscopic removal with or with- 
out implantation of radium or radon. 

(3) Exploratory thoracotomy with im- 
plantation of radium or radon. 

The value of x-ray therapy is a disputed 
question. In early cases, deep x-ray therapy 
and local application of radium or radon oc- 
casionally lead to a cure. In advanced tu- 
mors only temporary improvement is ob- 
tained, but several months may be added to 
the patient's life. 

Bronchoscopic removal of the tumor is not 
the procedure of choice, and has been 
supplanted by other forms of treatment. 
Bronchoscopic implantation of radon seeds 
is probably of value, but no definite con- 
clusions can be drawn at the present time 
regarding its merit. 

Favorable results have been reported by 
radon implantation following thoracotomy. 

Conch(sions 

(1) Symptoms and physical findings are 
not diagnostic. 

(2) Early diagnosis can be made in a 
large number of cases by close cooperation. 

(3) 70-85 per cent of cases can be diag- 
nosed early by x-ray and bronchoscopy with 
biopsy or lung puncture. 

(4) Surgery is the treatment of choice. 

'.I. OihsniT. A., and DeBakey. .M.: Primary Pulmonan' Ma- 
lisnaney. Treatment by Total Pneumonectomy. Surg.. 
Oynec, and Obst. 6S:435 (Feb. 13) 1939. 



184 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



METRAZOL IN THE TREATMENT OF 
MENTAL DISEASE 

and 

A Report on its Use at the State Hospital 

R. H. Long, M. D., 

Asst. Supt. State Hospital, Morganton 

In 1935 von Meduna of Budapest, Hun- 
gary, gave a report on the treatment of 
schizophrenia by means of artificially in- 
duced convulsions, using Metrazol as the 
convulsive agent. The remission rate claimed 
exceeded by far the results attained with the 
usual forms of treatment, and naturally the 
entire medical profession as well as the laity 
became intensely interested in the procedure. 
In outlining the treatment he made the fol- 
lowing suggestions : 

Careful physical examination, with special 
emphasis on the cardiovascular system, 
should first be made. He listed as contra- 
indications evidence of coronary disease, his- 
tory of brain injury, acute febrile disturb- 
ance, menstruation, etc. The treatment 
should be given in the morning, breakfast 
being withheld. An initial dose of 5 cc. of 
the 10 per cent aqueous solution is admin- 
istered intravenously, using as large calibre 
needle as possible to insure rapid injection. 
He suggested that a total of twenty convul- 
sions be given at the rate of two or three 
each week, and suggested that the maximum 
dose should not exceed 16 cc. 

The convulsion is similar to the grand mal 
seizure of epilepsy, and follows a fairly uni- 
form course. Within ten seconds after in- 
jection the patient gasps for breath, blinks 
his eyelids, loses consciousness, and then 
passes into the tonic phase of the convulsion. 
All the muscles of the body are in a state of 
extreme contraction, the pupils are dilated, 
and the patient becomes cyanotic. Within 
twenty or twenty-five seconds the clonic 
phase begins and continues for an addition- 
al twenty or twenty-five seconds. During 
these phases of the convulsion breathing is 
entirely suspended. Following the clonic 
phase the patient is in a state of collap.se; 
cyanosis is extreme and stertorous breathing 
begins, with rapid return to normal. He is 
usually in a confu.sed state for an hour or 
so following the convulsion, when he returns 



Read before the Ninth District Medical Society of the Stitte 
of North Carolina at Morganton, September 28, 1939. 



to his pre-convulsive state and is able to 
resume his usual activities. 

It is next to impossible to prove the results 
of this treatment by statistics, for the fol- 
lowing reasons : 

1. It is diflicult to establish a satisfactory 
control sy.stem. The reasons for this are in- 
numerable, but of primary importance is the 
wide variation in the duration of individual 
untreated attacks. We often see cases, es- 
pecially of manic depressive insanity, clear 
up in a few days; but we also .s^ee cases 
presenting the same classical symptoms per- 
sist for years. 

2. Another difficulty in determining re- 
sults is the lack of uniformity in diagnosis. 
It seems to those of us who are treating the 
mentally ill exclusively that we see more and 
more cases presenting a mixture of schizoid 
and manic depressive .symptoms, and in mak- 
ing the diagnosis we naturally incline to the 
psychosis with the dominating symptoms. 
Therefore, in order to arrive at a definite 
opinion as to the efficacy of this or any other 
treatment in a given psychosis, only clear- 
cut cases should be included. In our series 
many cases showing a mixture of symptoms 
have been included ; consequently, the statis- 
tics are of more interest from the standpoint 
of mental illness in general than fi'om the 
standpoint of schizophrenia or manic depres- 
sive disease in particular. 

3. Perhaps the greatest difficulty in ap- 
praising results is due to the lack of uni- 
formity in interpretation of results, and un- 
til some definite standard is u.sed by all ob- 
servers the results claimed cannot be con- 
clusive. In tabulating our results we have 
used the classification suggested by Barbato 
as follows : 

(a) — FkU Remission: Return to previous 
level of adjustment ; complete in- 
sight ; no defect in content or affect ; 
and ability to resume former em- 
ployment. 

(b) — Social Remission: One of above re- 
quirements lacking. 

(c) — Improved: Two of above require- 
ments lacking. 

(d) — Not Improved. 

Experiences at the State Hospital at 

Morganton 

Much has been written about the size dose 

required. Our custom has been to give 3' i cc. 

as the initial dose, and in over 75 per cent 



April, 1S140 



METRAZOL— LONG 



185 



of our cases this dose has produced a con- 
vulsion. The patients as a rule gradually 
develop a tolerance for the drug, and when 
the dose fails to produce a convulsion it is 
our custom to increase it by '/j cc. on the 
next treatment day. A decided difference in 
individual susceptibility has been noted ; and, 
while we have had several patients react 
throughout the entire series of twenty con- 
vulsions to a dose held at 3'-^ cc, we have 
used a dose as large as 11 cc. 

In our earlier experience we gave three 
treatments weekly throughout the entire 
.series, but we have since modified this prac- 
tice to some extent. We are now giving the 
first five or six convulsions at this rate, and 
then, if improvement is noted, we gradually 
extend the interval between treatments un- 
til no further improvement occurs. 

It has been suggested that a total of 
twenty convulsions should be produced, but 
our experience has been that no arbitrary 
rule should be followed. If improvement is 
going to occur it usually does so after a 
relatively few convulsions — ten or less. In 
only a few cases have we observed a sus- 
tained improvement after this number. Al- 
most without exception all patients ob.ject 
violently to the treatment — describe it as a 
horrible and terrifying experience — and it is 
our general impression that more can be 
done by psychotherapy than by repeated con- 
vulsive seizures after some improvement has 
occurred and the patient has become more 
accessible and developed some insight. It 
has been suggested that fear of the shock 
may be the beneficial factor in the improve- 
ment noted in these patients, but other 
authors have disproved this claim. 

We have had only one serious accident in 
over 2000 convulsions. One male patient 
suffered a fracture of the neck of both 
femurs in his first convulsion. Dislocated 
jaws have been noted frequently, but are 
always easily reduced when the tonic phase 
of the convulsion has subsided. One patient 
after her sixth convulsion developed bron- 
cho-pneumonia and died sometime later. We 
do not feel this could be directly attributed 
to the treatment. Several observers have re- 
ported fractui'es of the bodies of the dorsal 
vertebrae, many of which produce no symp- 
toms. So far we have been fortunate in not 
running into this complication. 

Relapse, after apparent remission, has 
been observed in our series in several cases. 



This has been noted in several fairly chronic 
ca.ses, and in these two or more series of 
treatments have been given with the same 
successful result. In these cases we have 
now adopted the policy of "watchful wait- 
ing" ; and with the first indication of relapse 
we give two or three treatments, which 
usually serve to hold the patient on a fairly 
even keel. 

The treatment was begun here March 4, 
1938, and to date we have had 155 cases 
under treatment. This report deals only with 
the first 100 consecutive cases. In six in- 
stances it was discontinued because of some 
contra-indication. We have made no attempt 
to restrict its application to favorable cases 
only, but have given it to many who from 
their chronicity and the nature of their 
symptoms offered little hope of improvement 
or recovery. As has been stated, cases of 
more than two years' duration offer a poor 
prognosis. In our series 52 cases ill two 
years or longer were treated, and this, 
naturally, will affect the recovery rate; yet, 
in some of these we have observed distinct 
improvement. 

The following tables are presented to com- 
plete the statistical picture : 
TABLE 1 

Results in 91 Cases of Schizophrenia Classified With 

Respect to Duration of Illness Prior to 

Beginning Treatment 

Fvll Sorial Not 

Total Remission Remission Improved Improved 



Ihira- 
lioii 


.So. 


.No. 


Per 
Cent 


No. 


Per 

Cent 


A'o. 


Per 
Cent 


No. 


Per 
Cent 


i> months 
(»r les!s 


26 


r 


26.0 


11 


42.3 


8 


30.8 








li munths 
to 2 vrs. 


2r> 


7 


28 


8 


32 


a 


32 


2 


8 


-' yrs. 
to .5 yrs. 


2.'> 


3 


12 


6 


24 


6 


24 


10 


40 


1 IVIT 

.'» yenrs 


1.1 








, 


6.7 


7 


46.7 


7 


46.6 


Total 
No. 


91 


17 


18.7 


26 


28.5 


29 


si.g 


1» 


20.9 



Comment 

It is possible that we have been somewhat 
less generous in our interpretation of results 
than some other workers, but by combining 
full and social remissions we see the follow- 
ing results: 

In the group ill six months or less we ob- 
tained a remission rate of 69 per cent, while 
31 per cent improved. None of these cases 
failed to improve. In the group ill six 
months to two years the remission rate was 
60 per cent. Thirty-two per cent improved, 
while 8 per cent failed to show improvement. 



186 



NORTH CAROLINA 



In the group with a duration of two to five 
years the remission rate dropped to 36 per 
cent, while an additional 24 per cent showed 
improvement. In this group 40 per cent 
failed to show any improvement. In the 
group ill five years or longer we obtained a 
remission in only one case, or 7 per cent of 
the total. Forty-seven per cent improved, 
while 46 per cent failed to improve. It will 
be seen from this that results are inversely 
proportional to the duration of illness. 

TABLE 2 

Results in 91 L'nselected Cases of Schizophrenia 
According to Type 





Total 


Full 
Remissioii 


Sfrriitl 
Remission 


Inipi 


I'ol-ed 


Improved 


Tape 


No. 


Xo, 


Per 
. Cent 


Xo. 


Per 

Cent 


Xo. 


Per 
Cent 


-Vo. 


Per 
Cent 


Hebe- 
phrenic 


27 


3 


11.1 


4 


14.9 


11 


40.7 


9 


33.3 


Cata- 
tonic 


51 


13 


25.5 


19 


S7.3 


12 


28.5 


7 


13.7 


Para- 
noid 


13 


1 


7.7 


3 


23.1 


6 


46.1 


3 


23.1 



Commeyit 

It has been stated by practically all ob- 
servers that the catatonic type of schizo- 
phrenia is more apt to respond to this treat- 
ment than the other types, and this is dem- 
onstrated in our series, as shown in Table 2. 

TABLE 3 

Results in 9 Cases of Manic Depressive Disease 

Classified With Respect to Duration of Illness 

Prior to Beginning Treatment 

Full Re- Social Re- Im- .\ot 

t Total mission mission proved Improved 



Duration 


No. 


No. 


Per 
Ct. 


No. 


Per 
Ct. 


Xo. 


Per 
Ct. 


No. 


Per 
ft. 


6 mos. Man. 


2 


3 


100 




















less Dep. 





























S^mos. f M^n 


3 


4 


oe.e 


1 


33.3 














2 rears iDeP- 





























2 years Man. 





























5 years ""^P- 


1 


1 


100 




















Over 1 M!in- 


2 


1 


50 


I 


SO 














5 years [ Dep. 


I 








1 


100 














Total Number 


9 


6 


60.7 


3 


33.3 















Comment 

Although the number of cases in this 
series is small, the results obtained are strik- 
ing. Remissions were obtained in all cases 
regardless of duration, and there seemed to 
be no difference in result with respect to the 
manic or depressive phase of the disease. 
Of course, it is impossible to say with as- 
surance what the outcome of the cases of 
short duration would have been without 
treatment, but in the four chronic cases who 
remitted and who had been ill two vears or 



MEDICAL JOURNAL April, UMO 

longer, the remission seemed to be the direct 
result of treatment. 

TABLE 4 

Results in 91 Unselected Cases of Schizophrenia 
Regardless of Duration of Illness 

Xumlier Perc entage 

Full Remission 17 18.7 

Social Remission 26 28.6 

Improved 29 31.8 

Not Improved 19 20.9 

Comment 

Although nothing very startling is shown 
by this table, it should be kept in mind that 
in the group of 91 cases 44 per cent were 
considered chronic, with a duration of two 
years or longer. In spite of this our general 
impression is that, taking the group as a 
whole and considering all of the facts, bet- 
ter results have been obtained than would 
be expected in the usual treatment of these 
cases. 

We have made an effort to compare the 
duration of hospitalization in a group of 
treated cases with a group of untreated 
cases as similar as could be obtained, and 
we find a material shortening of the time 
spent in the hospital. For example, in 16 
cases, ill six months or less before admission, 
the average hospitalization period was three 
months and four days with treatment ; while 
in a similar number of cases with this same 
duration of illness the average hospitaliza- 
tion period was eight months and twenty- 
three days without Metrazol treatment. 
Similarly, in a group of 12 cases, ill six 
months to two years before admission, the 
average stay in the hospital was six months 
and twenty-five days with Metrazol; while 
in a similar group of untreated ca.ses the 
average hospitalization was eighteen months 
and seventeen days. In the treated ca.ses in 
this group the average stay in the hospital 
after treatment was two months and eleven 
days. Of course, we are fully aware of the 
expected individual variation in these ca.ses, 
but these figures do seem to shorten ma- 
terially the period of hospitalization. 

It .seems to us that, although much can be 
learned from statistics, the ob.servations by 
unbiased workers on the reactions and re- 
habilitation of the individual cases is of tre- 
mendous importance. We have seen many 
ca.ses make almost dramatic imi)rovement, 
whose previous appearance and reactions in- 
dicated a graduall.v developing deterioration 
extending over a period of months and even 



April, 1940 



ANEMIA— MOREHEAD 



187 



years. The most gratifying remark we have 
heard from relatives of patients has been 
"Doctor, I had given up hope. I never ex- 
pected to see her this well again." This has 
been heard many times since the Metrazol 
treatment was begun. While there may be 
some doubt as to the completeness or the 
permanence of the recovery of these patients, 
we are convinced that the treatment is bene- 
ficial in many cases. 

Summanj 

1. Metrazol therapy is not a panacea for 
all mental ills, but it is a distinct adjunct to 
psychiatric therapy. Its greatest field of use- 
fulness seems to be in stuporous, inaccessible 
cata tonics. 

2. In selected cases of schizophrenia re- 
missions may be expected in 65 to 70 per 
cent, as compared with 40 per cent in un- 
treated cases. If improvement is going to 
occur it usually begins after a relatively few 
convulsions. 

3. In chronic and apparently deteriorated 
cases substantial improvement frequently oc- 
curs, and sub.sequent hospitalization is made 
less difficult and expensive. 

4. The period of hospitalization seems to 
be definitely shortened. 



THE DIAGNOSIS AND TREATMENT 
OF THE ANEMIAS 

Robert P. Morehead, M.D. 

An anemia occurs when the hemoglobin of 
the blood falls below the normal limit. Since 
the entire amount of hemoglobin in the body 
is contained in the red blood cells, an intelli- 
gent understanding of their metamorphosis 
is prerequisite to a proper understanding of 
hemoglobin metabolism and the etiology and 
pathogenesis of the anemias. 

Red blood cells are derived from the sinu- 
soidal endothelium of the bone marrow, 
erythropoiesis being an intravascular phe- 
nomon.'" From the sinusoidal endothelium 
comes the megaloblast, the most primitive 
of the erythrocytes. The megaloblast is an 
unusual cell in that it requires for matu- 
ration those sub.stances essential for the 
growth of most cells, plus an anti-anemic 

Krom the Department of Patholopy. School of Medieal Seient-es. 
Wake Forest Collegre. Read before the First General Session 
of tlie Medical Society of the State of North Carolina, Ber- 
muda Cruise, May 10, 1039. 

I. Maximovv. A.: A Textbooli of Histology, Philadelphia, 
V. B. Saunders Co.. 19.11. 



principle. The anti-anemic principle is 
formed by the interaction of an extrinsic 
factor from the food with an intrinsic factor 
from the ga.stric and duodenal glands. After 
formation, it is absorbed by the stomach and 
intestine and is stored in the liver and, to a 
les.ser degree, in other organs. 

The intrinsic and extrinsic factors have 
not been identified chemically but the former 
is probably enzymic in nature'-', while the 
latter is closely associated with protein'^'. 
Little is known about the anti-anemic factor 
which is stored in the liver except that it is 
essential for the maturation of erythrocytes 
from the megaloblastic stage. 

When there is a deficiency in the anti- 
anemic factor, the bone marrow undergoes 
an erythroblastic type of hyperplasia, the de- 
gree of hyperplasia being in direct propor- 
tion to the number of circulating erythro- 
cytes'". The hyperplasia is confined to the 
young or megaloblastic erythrocytes, and 
maturation does not take place. The primi- 
tive red blood cells die in situ, hemoglobin is 
.set free, iron is split off, and bile pigment 
formed. This results in an increase in the 
.serum bilirubin of the blood. This, along 
with the profound anemia, accounts for the 
lemon yellow color commonly seen in per- 
nicious anemia. Those cells that do undergo 
complete maturation have an increased 
amount of hemoglobin to transport, since 
iron is present in normal amount. In order 
to cope with this situation, the concentration 
of hemoglobin becomes greater in each cell 
(the cell becoming hyperchromic) and there 
is an increase in the size of cells (cells be- 
coming macrocytic). The color and volume 
indexes are obviously increased. The result- 
ing anemia is a hyperchromic macrocytic 
anemia. 

A hyperchromic macrocytic anemia may 
result from: (1) a deficiency in the intrinsic 
factor — e. g., atrophy of the gastric mucosa 
in pernicious anemia, gastrectomy, infiltra- 
ting carcinoma, etc.; (2) a deficiency in the 
extrinsic factor — e. g., sprue; (3) failure of 
the intestine to absorb the anti-anemic prin- 
cipal — e. g., ileitis, intestinal stricture, gas- 
tro-colic fistulae; or (4) failure on the part 
of the liver to store the anti-anemic factor 

• Willtarson, J. F.. and Klein, L.: Relationship Between 
Anti Anemic Principle and Liver. Lancet 2:029. 1933. 

.1. Castle, W. B.. and Minot. G. R.: A PatholoRlcal Physlo- 
iogical and Clinical Description of tlic Ancnii.a.s. New 
Yorli. Oxford Press, 1036. ., ,. 

I Dameskek, W. : Biopsy of Sterniil Bone Marrow; Its 
Value in Study of Diseases of Blood Forming Organs, 
Am. .1. M. Sc. 185: 617, 1935. 



188 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



— e. g., the late stages of portal cirrhosis, 
toxemias of pregnancy, etc. 

One may readily see that there are many 
hyperchromic macrocytic anemias, but the 
most important of these is pernicious or 
Addisonian anemia. The etiological factor 
in this di.sease is in all probability a defici- 
ency in the intrinsic factor resulting from 
atrophy of the gastric mucosa. Other prod- 
ucts of gastric secretion suffer also, particu- 
larly hydrochloric acid, and a diagnosis of 
pernicious anemia in its presence is likely 
to be erroneous. The symptoms are those of 
anemia and gastro-intestinal disturbances. 
To these may be added the all important 
changes in the nervous system. In Herman's 
series, 72.5 per cent had spinal cord involve- 
ment (postero-lateral sclerosis), and 15.7 
per cent showed mental changes'". The neu- 
rological lesions are pi'obably the result of 
anoxemia of the nervous tissue along with a 
deficiency in some substance necessary for 
the health of nerve cells. Since this is a true 
hyperchromic macrocytic anemia, the labo- 
ratory findings are those which were dis- 
cussed in preceding paragraphs. 

The treatment of macrocytic anemias re- 
solves itself into supplying the existing de- 
ficiency. If the deficiency is in the extrinsic 
factor — e. g., sprue — therapy will consist in 
supplying a diet rich in protein (beef con- 
tains large amounts of the extrinsic factor). 
If the deficiency is the result of failure of 
the gastric mucosa to elaborate the intrinsic 
factor, or faulty ab.sorption of the anti-ane- 
mic factor by the intestine, or its storage by 
the liver, the treatment will consist of an 
attempt to correct the underlying condition, 
in addition to supplying the deficiency. 

From a study of the pathological physi- 
ology of this condition, it is obvious that the 
therapeutic agents are stomach and liver. 
The latter is the more commonly used and 
eflfective agent in macrocytic anemias, but 
cases are seen which are refractive to liver 
and respond promptly to ventriculin (des- 
sicated hog stomach). The dose of liver, 
like any other remedial agent, is that amount 
which will produce the desired therapeutic 
effect. Attempts to test the liver principle 
have been unsuccessful, and the substance 
must be as.sayed biologically. The only satis- 
factory subject thus far has been the un- 
treated pernicious patient showing a red 

r,. Il<-niinn. M.. Miwt. II.. nixl .Inllifro. N.: I'hychnses As- 
six'iatfd with PeriilcliHis .\iioiiiia., .\rcli, Ntnirol. hikI 
I'livshiat. :<>t: 31» (.\iis.) 1037. 



blood cell count of three million or less. The 
form in which the factor is given matters 
little; but the extracts for intramuscular in- 
jection are more convenient in that the dose 
is given at rather infrequent intervals. Ade- 
quate treatment is of paramount importance, 
and the criteria for adequacy include eleva- 
tions of erythrocyte and hemoglobin values 
to normal levels and maintenance of the nor- 
mal size of the erythrocytes. Reticuloyte 
counts should be performed daily until a 
satisfactory response has been obtained. The 
color index should be determined weekly, 
and, if it .should fall below the normal level, 
supplementary iron therapy instituted. 

The second great group of anemias are 
the hypochromic anemias. These are the 
anemias in which there is a deficiency in 
hemoglobin. The hypochromic anemias are 
usually a .symptom of .some other disease, 
and they constitute 95 per cent of all of the 
anemias. They may be defined as a state of 
the blood in which the loss of hemoglobin has 
exceeded the loss of erythrocytes. If the 
blood loss is acute — e. g., acute hemorrhage, 
the resulting anemia will be hypochromic 
and normocytic. On the other hand, if the 
anemia becomes chronic cells of normal size 
(normocytes) are no longer needed to carry 
the hemoglobin and they become smaller 
than normal (microcytes). The resulting 
anemia will be hypochromic and microcytic. 
The anemias of accelerated blood destruc- 
tion — (e. g., familial hemolytic icterus, in- 
fections, and poisons) ; and depression of 
marrow function (e. g., idiopathic aplastic 
anemia, cachexia, and malignant infiltration, 
etc.,) will also produce a hypochromic and 
microcytic type of anemia. 

Since hypochromic anemias are the result 
of a deficiency in hemoglobin, iron is obvi- 
ou.sly the remedial agent. In spite of the 
tremendous amount of work done, there is no 
agreement regarding the minimum amount 
of dietary iron required by a healthy adult. 
We do know however that "for optimum re- 
generation of hemoglobin in patients with 
anemia, much greater amounts of medicinal 
iron are required than are neces.sary for the 
synthesis of hemoglobin."'"' It appears that 
an excess is needed because of inefficient ab- 
sorption or because after absorption only a 
jiortion of the metal is put into physiologic 
u.se. There appears to be no correlation be- 

(1. Fowler. W. M.. niul Diirer. .\. P.: RetfiitUm nnrl Utili- 
zation of Orallv .Vilininlstered Iron, .\rt-li. Int. Meil. 30; 

.1111 (.\pnl) io;i7. 



April, 1940 



ANEMIA— MOREHEAD 



189 



tween the retention and utilization for new 
hemoglobin of orally administered iron"". 
We give all patients suffering from hypo- 
chromic anemias 100 grains of iron and am- 
monium sulphate daily until the maximum 
hemoglobin content is obtained. 

Liver and copper have no place in the 
treatment of hypochromic anemias. The ad- 
dition of copper leads to diminished reten- 
tion of iron, but also to slightly increased 
utilization. The addition of liver is followed 
by slightly decreased iron retention. 

Commercial liver preparations, apart from 
their iron content, are wholly ineffective in 
the treatment of hypochromic anemias. 

It is a well known fact that the peripheral 
blood does not always reflect accurately the 
condition of the hematopoietic .system. The 
blood picture is the result of many complex 
factors which are concerned with the 
growth, destruction, and liberation of the 
various elements of the blood. Diseases of 
the hematopoietic system may therefore 
occur without changes in the peripheral 
blood, and likewi.se diseases not primarily 
concerned with hematopoiesis may produce 
changes that suggest disease of the blood- 
forming organs. From these considerations 
it becomes evident that in some cases it 
would be desirable to stud}' the organs of 
blood formation during life in conjunction 
with studies of the peripheral blood. By cor- 
relation of the two an accurate diagnosis can 
usually be made and an intelligent thera- 
peutic campaign instituted. 

A method which has been found superior 
to the sternal puncture method, and which 
in our hands has been followed by no com- 
plications, is as follows:'" 

"Using rigid aseptic technique, the skin 
and subcutaneous tissue are infiltrated with 
a 2 per cent solution of procaine hydrochlo- 
ride for 2 cm. on either side of the midline 
and for a distance of .3 cm. below and above 
the level of the fourth rib. A short incision 
is then made in the midline down to but not 
through the periosteum. A small needle is 
introduced between the bone and periosteum 
and a small bleb produced. The subperios- 
teal space is then infiltrated over an area of 
about 2 cm. A small incision is then made 
in the periosteum and both sides elevated. 
The spike of a 1 cm. trephine is introduced 
through the ventral table of the sternum and 

7. Moreheart, R. P.: Biopsy of The Sternal Bone .Marrow. 
South. Med. and Surg. 99: 5.55 (Nov.) 1937. 



a shallow groove produced by a gentle rotary 
movement of the trephine. The instrument 
is withdrawn, the spike removed (this is a 
precaution against entering the mediasti- 
num) , the trephine reinserted and the cortex 
penetrated ; the patient experiences a slight 
sensation of pressure as the marrow cavity 
is entered. The trephine is gently rocked to 
break up the trabeculae and the button of 
bone removed and placed immediately in 
nine parts of the following solution to which 
one part 10 per cent formalin has been added 
immediatelv before use : 



"Potassium bichromate 
Mercuric chloride . . 
Distilled water . . . 



2.5 gm. 
.5 gm. 
100 cc. 



"A few small fragments of marrow are 
then removed, with a sharp spoon curette, 
and handed to an assistant who places sev- 
eral in the fixing solution, the remainder be- 
ing used for smears. The latter are pre- 
pared by gently grasping the fragment with 
fine forceps and pulling it evenly over clean 
slides. As the smear dries it is immersed in 
pure methyl alcohol for ten seconds. In the 
meantime the surgeon packs the marrow 
cavity with gauze until bleeding stops. The 
perio.steum is then allowed to cover the 
wound and the skin is closed with No. 00 
plain catgut." The material is immediately 
sent to the pathologist for microscopic study. 

Conclusion 

In order to study an anemia properly one 
must first determine the size and hemoglobin 
content of the cells as compared with the 
normal. This is done by estimating the color 
and volume indexes. It is also of advantage 
to know whether the anemia is the result of 
increased blood destruction or decreased 
blood formation. The icterus index, along 
with the reticulocyte count, affords this in- 
formation, since the former is the most re- 
liable index of peripheral blood destruction, 
and the latter of blood formation. If the 
peripheral blood does not give enough infor- 
mation we believe that the physician is then 
justified in trephining the sternum. 

During the past ten years, much progress 
has been made in the diagnosis and treat- 
ment of the anemias. The treatment of an 
anemia today is as specific as the treatment 
of an infectious disease. Through a little 
additional effort on the part of the physician, 
the patient will reap much benefit from the 
modern march of hematology. 



inn 



NORTH CAROLINA MEDICAL JOURNAL 



THE MENTAL HYGIENE OF CHILD- 
HOOD IN THE PUBLIC HEALTH 
PROGRAM 

Raymond S. Crispell, M. D. 
Durham 

The Points in Common in Phtfsical 
uinl Mental Hygiene 

The fields of physical and mental hygiene 
overlap, and the special workers in public 
health and those in mental hygiene have a 
great deal in common. Both sets of workers 
are grounded in medicine, but are socially 
minded and frankly view their activities as 
related to those of social agencies. Both are 
interested in environments as well as in per- 
sons. 

The mainsprings of both the physical and 
the mental health programs are derived 
from a common social attitude and humani- 
tarianism. Both the mental hygienists and 
the public health workers consider their af- 
fairs community affairs. Much of the work 
and organization in psychiatry and mental 
hygiene, as well as in public health, are car- 
ried on as governmental responsibilities and 
functions. The public health worker is called 
upon to do all that medical work in a com- 
munity which is left undone by the private 
practice of medicine. At the present time in 
most communities the work in mental hy- 
giene is left undone; so the public health 
worker is commissioned to assume this re- 
sponsibility. Among the responsibilities of a 
public health worker ar^ not only the pres- 
ervation and promotion of both physical tnid 
mental health, but often the actual care and 
management, at least in emergency, of men- 
tal and nervous patients. 

It is no wonder that from both theoretical 
and practical considerations public health 
has often considered incorporating mental 
hygiene in its i)rogram, and sometimes has 
even done so. With such dread communi- 
cable diseases as typhoid, dii)htheria, small- 
pox, etc.. under control, public health may 
be looking around for new fields to conquer. 
If one accepts Winslow's definition of public 
health as "the art and .science of preventing 
disease, prolonging life and promoting physi- 
cal and mental etiiciency through organized 
community effort," then public health has 

Read bi'ftMT tlu- Sortion on I'ublic Mt-jilth of the Modleal 
Society of the Stute of North (iirolina, neriauda Cruise 
May 14. 1931). 



April, 1940 

already assumed a responsibility for mental 
hygiene. Certainly, there should be a close 
relationship between the two. 

The Points of Difference 

But it is nece.ssary to remember the points 
of difference between physical and mental 
hygiene as well as the points in common. 
Mental hygiene is a vast, difficult and un- 
crystallized subject which has its own con- 
cepts and techniques. Psychiatry and men- 
tal hygiene diverge both from medicine and 
from public health in going beyond physical 
and chemical and physiological factor.s into 
imponderable psychological ones which de- 
mand a different point of view and a shift 
in approach. Factors in mental, nervous and 
emotional disorders are not onlv mixed by 
being partly "physical" and partly "mental", 
but are also apt to be multiple, complex and 
variable. Each patient has to be individu- 
alized. Mental factors do not lend themselves 
to the mass approach and to the mass action 
that is customary in most public health work. 
It is a well-known fact of public health prac- 
tice that preventive measures can be applied 
best where the factors are simple and specific 
and where causal relations are best under- 
stood. One cannot line up children and in- 
ject them with mental hygiene as with diph- 
theria toxoid, for example; or vaccinate them 
aganst mental and nervous breakdowns. 
But, borrowing a figure of speech from pub- 
lic health, children can be immunized against 
some harmful situations as well as against 
some physical diseases. It follows that there 
will always need to be special workers in 
public health and special ones in mental 
h.vgiene. Sometimes their activities will be 
in common, sometimes they will overlap, and 
sometimes they will be divergent. It seems 
not only very desirable but very necessary 
that the two sets of workers understand each 
other and their respective fields and activi- 
ties. 

The physical and mental hygiene of in- 
fancy and childhood especially overlap — in- 
deed, are in.separable. In order to limit a 
large subject, this discussion is going to con- 
centrate upon the mental hygiene of child- 
hood in the public health program. 

Th< Iiieidental Benefits to Mental Health of 
Certain Public Health Procedures 

So close is the association and so great is 
the interaction of body and mind that any- 



April, 1940 



MENTAL HYCaENE— CKISPELL 



191 



thing that promotes physical health at the 
same time promotes mental health, and vice 
versa. It is difficult sometimes to say where 
physical hygiene leaves off and mental hy- 
giene begins. The ancient ideal of a sound 
mind in a sound body still holds, and should 
still be sought. 

Some of the public health activities and 
interests that have incidentally increased 
mental health, especially those that have had 
a bearing on the mental hygiene of infants 
and children, might be mentioned. All of 
the public health activities that improve the 
environment — such as slum clearance, better 
housing, better food and water supplies and 
inspections, and better sewerage disposal — 
have vastly promoted mental as well as 
physical health and happiness. The public 
health control of communicable diseases has 
not only prevented death, but has conserved 
mental and physical health, especially of 
children. The control of the diarrheal di- 
.seases of infants without a doubt has bene- 
fited the mental as well as the physical health 
of the infant and the child There are many 
specific diseases in which the infective agent 
has a special predilection for the brain. Any 
decrease in the incidence of these disorders 
that public health and modern medicine have 
been able to bring about must certainly be 
considered a great contribution to mental 
hygiene. 

Venereal infections in general and -syphi- 
litic infections in particular are great rava- 
gers and destroyers not only of the nervous 
system, but also, directly and indirectly, of 
the mind; so that mental hygiene considers 
venereal disease control part of its program, 
as does public health. Quoting Smillie : "The 
most concrete results in prevention of any 
type of mental disease have been secured 
through prevention of syphilis, or more pro- 
ductive still, through adequate treatment of 
early syphilis." It is heartening to those in- 
tere.sted in the mental hygiene of infants 
and children to see the legislation in North 
Carolina requiring serological tests of ex- 
pectant mothers, and the inci^eased activities 
in the diagnosis and treatment ol congenital 
syphilis. 

Nutritional deficiencies cause mental and 
nervous diseases. The outstanding example 
of this is pellagra. Mental hygiene will reap 
benefits from the public health work and 
education along these lines. 



Numerous cases of intra-uterine or pre- 
natal maldevelopments are encountered 
among infants and children in neurology 
and psychiatry. Theoretically, and probably 
practically, the number of these will be di- 
minished by the increased attention public 
health is giving to maternal welfare. Some 
neuropsychiatrists see in birth in.juries one 
of the greatest sources of serious neuropsy- 
chiatric conditions, and great hope rests in 
the better obstetrical care that public health 
is striving to bring about. 

Mental Hygiene Principles of Infancy 
and Childhood 

Only a few of the principles of mental 
hygiene for the infant, the pre-school child 
and the school child can be indicated here. 
Those who are interested can be referred to 
the sixth edition of Rosenau's text-book of 
Preventive Medicine and Hygiene, in 
which can be found a very excellent chapter 
on mental hygiene by A. Myerson. 

The physical and the mental h.vgiene of 
the infant are one and the same. The infant 
needs a calm environment, a lack of over- 
stimulation, and a chance to feed and to rest 
properly and to grow and develop normally. 
In infancy mental and physical habits are 
very closely associated. Good habits can be 
encouraged and established and, at the same 
time, poor ones can be avoided. One cannot 
distinguish those habits which belong to 
physical hygiene from those which are a 
part of mental hygiene. The baby does not 
need two different kinds of hygienists; 
rather, it needs one who is proficient in the 
combined physical-mental hygiene of in- 
fancy. 

It is different when we come to the child. 
Here there is a rapid growth of that which 
we are accustomed to call "mind" or "be- 
havior". Mental and emotional problems can 
be distinguished from physical ones. Child- 
hood is the golden period of mental hygiene. 
As the twig is bent, so grows the tree. When 
one considers that our present psychological 
theories are to the effect that mental and 
emotional attitudes and habits, which form 
the very foundation and basis of the per- 
sonality, are laid down in childhood, it is no 
wonder that the mental hygienist is tremen- 
dously interested in children and desires to 
start to function as a specialist in the period 
of childhood. 

The pre-school child period extends from 



192 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



the time that the habits of walking, talking 
and elimination are fully established until 
the time the child goes to school regularly. 
It is a comparatively short period, from 
about the age of three until five or six, but 
it is a very important one from the stand- 
point of both physical and of mental hygiene. 
Physically, the diseases and injuries, perils 
to growth and development, that beset a 
young child are encountered. Mentally and 
emotionally, the child has to absorb in some 
measure the culture that the race has taken 
thousands of years to accumulate. The child 
at this period obtains mental and emotional 
habits and attitudes that are apt to be life- 
long. During this period the child should be 
immunized not only against certain diseases, 
but also against certain experiences. 

WTien one considers all the child has to 
learn, one should be tolerant and patient. 
The greatest lessons he has to learn are 
those of socialization — ^to adjust and to get 
along with other people, and also to benefit 
from experience. It mu.st be remembered 
that play is more than recreation for the 
child ; it is experience. The child should be 
taught endurance and fortitude. Discipline, 
to be of the right sort, has to be individua- 
lized for each child, taking into considera- 
tion his physical and temperamental make- 
up. Too-harsh discipline should be avoided. 
It may make for a crushed passivity, or for 
rebellion. Probably a greater peril is too 
little discipline, or spoiling. There has been 
a misinterpretation of the so-called new child 
psychologj-, in the idea that the child should 
express himself unhampered and unpunished. 
Nothing would be worse mental hygiene. 
Such a child would not be free, but a victim 
of his own whims and impulses. There would 
surely be continuous clashes at school and 
in society with the necessary conventions 
and perhaps later with laws. 

Since there are not enough psychiatrists 
and mental hygienists to go around, and 
since the parts played by parents and the 
schools in the broad education of the child 
and in the inculcation of mental hygiene 
principles always need supplementing, pub- 
lic social and health workers have a part to 
play. They can make physically and mental- 
ly sanitary the environments of the home 
and the school. They can provide the proper 
facilities and setting for play. With some 
training in mental hygiene, public health 



workers can aid parents in adjusting the 
home life of the child to correct unhealthy 
habits and tendencies that might lead to 
serious future difficulties. This training 
would enable public health workers to make 
mental hygiene an integral part of the gen- 
eral public health program. At the same 
time, it would teach the public health work- 
ers to recognize their limitations and to elicit 
the aid of specialists in difficult and complex 
problems. 

There are certain conditions that are pub- 
lic health problems because of their great 
prevalence and because the private practice 
of medicine unaided and without some com- 
munity eff'orts cannot adequately cope with 
them. Among these are some well-known 
and frequent neuropsychiatric conditions. 
Because of their prevalence and because 
they demand organized efforts, mental and 
nervous diseases are sometimes spoken of as 
among the greatest of public health prob- 
lems. In this country there are nearly half 
a million hospital beds devoted to mental and 
nervous diseases — more than to all other 
kinds of diseases combined — and each year 
about 100,000 new cases enter mental hos- 
pitals. With good mental hygiene, especially 
if it is begun in childhood, many of these 
mental disorders can be prevented, and with 
good psychiatric practices many can be modi- 
fied or cured. 

It has been estimated that from 2 to 4 per 
cent of the population are to some degree 
mentally or intellectually deficient, as op- 
posed to mentally diseased. These defectives 
are often serious social problems. 

It has also been variously estimated that 
from .2 to 2 per cent of the population are 
epileptic. Some authorities maintain that as 
high as four per cent of the population have 
a tendency to be convulsive. Most cases of 
epilepsy start in childhood, and this is the 
period in which an attempt to control the 
condition by adequate social and medical 
measures should be instituted. To do so 
properly will tax the combined resources 
and facilities of those concerned with public 
health and those who are interested in men- 
tal hygiene. 

While there are sufficient psychiatric cases 
among children so that a whole new specialty 
of child psychiatry has been establi-shed, and 
while the problems in mental hygiene of 
children are numerous and diverse, there are 
few cases of major mental disorders or 



April. 19-10 



MENTAL HYGIENE— CRISPELL 



193 



major psychoses. Dementia praecox and the 
manic-depressive psychoses represent the 
two greatest major psychoses. These develop 
so rarely before the age of fourteen that one 
should hesitate to make these diagnoses in 
children. It seems very desirable to be able 
to recognize the children who are predis- 
posed to these disorders, but there are cer- 
tain great and almost insuperable difficulties 
in doing this. Psychiatrists and mental hy- 
gienists have a fairly good idea as to the 
types of personality in which these disorders 
may develop, and so they are able to recog- 
nize the predisposition of some children to 
certain psychoses. However, those who have 
not had special training can not be taught 
to do so without some danger both of miss- 
ing many conditions and of considering 
many children as pre-psychotic who are not. 

Annually thirty to forty thousand new 
patients develop dementia praeco.x, and alto- 
gether nearly one-half of the beds devoted 
to mental diseases in this country are oc- 
cupied by sufferers from this disorder. This 
makes dementia praecox a greater health 
problem than tuberculosis. In children one 
encounters pre-dementia praecox rather than 
fully developed cases. As in tuberculosis, 
early diagnosis seems very desirable, for it 
is in the early cases that most can be done. 

The problems in child psychiatry, other 
than tho.se of mental deficiency and epilepsy 
and the major psychoses which have been 
mentioned, are so numerous and diverse that 
it is difficult to classify them. A group of 
problems in emotionalism and in neuroticism 
in children, .somewhat related to the prob- 
lems of the psychoneuroses in adults, is en- 
countered. There is a large and distinctive 
group of problems known as the primary 
behavior disorders and conduct disturbances 
that both the mental hygienists and the pub- 
lic health workers see. They should be fa- 
miliar with them and prepared to manage 
them. 

L'chdionships of Public Health and 
Mental Hygiene 

The State has the main responsibility in 
the care of the mentally ill and the mentally 
deficient, and in a general mental hygiene 
program. This should be centralized in a 
State Department of Mental Hygiene with a 
Commissioner of Mental Hygiene, just as 
there is a State Department of Health with 



a Commissioner. These two State officers 
and these two State departments should 
work in collaboration. The State Depart- 
ment of Mental Hygiene and the State Com- 
missioner should have oversight and direc- 
tion of all the activities and endeavors along 
the lines of mental hygiene. The State should 
maintain medically and p.sychiatrically ade- 
quate State hospitals. Some special*provisions 
somewhere in the State set-up should be 
made for child psychiatry. In modern psy- 
chiatry the psychopathic hospitals that con- 
centrate on early and recoverable mental con- 
ditions rather than on custodial care play a 
great and important role. Since most psy- 
chiatric conditions in children are acute and 
recoverable, probably the special provisions 
for children should preferably be in the acute 
psychopathic rather than in the State hospi- 
tals. This would also tend to increase the 
very desirable segregation of children from 
adult and chronic patients. 

In the local communities, counties, and 
municipalities, unless they are very large 
and wealthy, it does not seem feasible to 
have resident psychiatric and mental hygiene 
officers and workers such as the public health 
program has. Even separate divisions of 
mental hygiene in the local public health or- 
ganization are not advised. Local needs can 
be fairly well supplied by traveling psychi- 
atric and mental hygiene clinics under the 
direction of the State Commissioner of Men- 
tal Hygiene and the State hospital sy.stem. 
This is the system in effect in the most pro- 
gressive and well-organized states. It still 
leaves the public health workers, officers and 
nurses and the private practitioners as the 
first line of resident defense in public mental 
hygiene and psychiatric practices, and makes 
it imperative for all the health workers to 
have some understanding of mental and 
nervous disorders and to be "mental hygiene 
minded", especially in regard to infants and 
children. 

Local health officers and nur.ses who are 
alive to the needs of their community will 
find that the whole broad field of mental 
hygiene touches — in fact, invades their more 
specific activities and functions at every 
point. The local health workers should be 
familiar with mental diagno.ses and with the 
care of mental diseases and deficiencies. 
They should know how to go about obtain- 
ing specialized help if this is necessary, and 
how to cooperate with visiting clinics, and 



194 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



they should know something about the 
mental hygiene facilities such as homes, 
specialized schools, hospitals, colonies, and 
institutions, both public and private chari- 
table ones. 

A modern State hospital system has pro- 
visions for some sort of parole or probate 
for discharged and convalescent patients. 
Sometimes the readjustment of the mental 
patient from the sheltered hospital condi- 
tions to the home situation, and the gradual 
assumption of the burdens of life may cause 
relapse. Through the psychiatric social 
workers the hospitals should give some in- 
termittent help and guidance, but the local 
health workers should supplement this with 
more continuous local assistance. 

Some states provide for visiting local men- 
tal hygiene clinics for children — or child 
guidance clinics, as they are called — in addi- 
tion to those for adults. These child guid- 
ance clinics are excellent and are in line 
with the most advanced mental hygiene pro- 
cedures ; however, they consume a great deal 
of professional time and were it not for their 
value in research in child psjchology, they 
are so expensive that they would have to be 
classed as medical and social luxuries. At 
present only large and wealthy communities 
or well-endowed organizations maintain 
these separate child guidance clinics. They 
cannot function effectively without the coop- 
eration of other welfare and health agencies 
on whom they rely, not only in obtaining 
and arranging for their cases, but also in 
carrying out their recommendations. 

The school system and the public health 
department should cooperate in a communi- 
ty in medical inspection in the schools, and 
some work in mental hygiene should be in- 
corporated. The medical inspector of the 
school system should be prepared to aid in 
the recognition and the handling of children 
who are experiencing mental and emotional 
handicaps and difficulties. Health aid should 
even extend to the recognition of cases of 
mental deficiency and to the establishment 
of the special classes which have been found 
so beneficial for problem children. 

Many times someone is needed to give a 
psychiatric opinion about a delinquent child. 
This happens especially when a juvenile 
court is functioning in a modern and pro- 
gressive way and wants to take into con- 
sideration all the factors in its deliberation 
about a case. K there is no specialized help 



available, the public health officer should be 
prepared and willing to render these ser- 
vices. Similar help is also often needed in 
problems concerning the adoption of chil- 
dren 

WTlson G. Smillie, a great authority on 
public health, in his book on Public Health 
Administration emphasizes the importance 
of mental hygiene in the public health pro- 
gram in general and the importance of the 
public health nurse in the mental hygiene 
work in the local communities in particular. 
Quoting Smillie, "Public health workers, es- 
pecially public health nurses, should be 
trained to understand people as well as di- 
sease, and to deal with common mental hy- 
giene problems as a part of their daily ac- 
tivities in their contacts with the communi- 
t.v." 

In both public health and mental hygiene 
great reliance is placed on the education of 
the public and both endeavors have already 
reaped advantages from their educational 
work, notably public health. But mental hy- 
giene has also succeeded in dispelling some 
of the ignorance and has changed some of A 
the attitudes concerning mental and nervous M 
diseases. In this educational work the pro- 
grams of the health worker and the mental 
hygiene worker can reinforce each other. 

There is little doubt that the teachings of 
mental hygiene have already been widely 
diffused to the advantage of human health, 
happiness and efficiency. Attitudes toward 
children, their rearing, their training, and 
their education have been revolutionized in 
the last generation. Psychiatry and mental 
hygiene have thrown a great deal of light on 
the sexual life of normal and abnormal per- 
sons. Unless the programs for sex hygiene 
and education utilize these findings and pro- 
ceed along psycho-sexual lines, they will get 
nowhere. The child is not without sexual 
curiosity. A young child's questions as to 
sex should be met frankly and openly. No 
covered and morbid curiosity should be al- 
lowed to develop. No information beyond a 
young child's under.standing or beyond a 
simple, honest answer to his questions should 
be given. No great or complicated amount 
of sexual instruction is usually needed in 
what is known as the latency period, from 
the age of five or six until around eleven 
(and any is best given to the individual child 
rather than to any group of children). After 
that the child should be gradually, calmly, 



April, 1940 



VITAMINS— CARLSSON 



195 



jn-epared for the stress and strain of puberty 
and adolescence by appropriate instruction 
as to sex. 

Just as there are voluntary associations 
such as the Red Cross, tuberculosis associa- 
tions, etc., that are auxiliary to public health 
work, so are there organizations to promote 
mental hygiene, such as state and local men- 
tal hygiene societies, which play a definite 
and valuable part in the community mental 
hygiene program. Mental hygiene societies 
study the cause, prevalence and prevention 
of mental disorders, stimulate interest in 
them and help educate the public as to them 
and, in general, serve as a clearing house for 
information about them. If they at all war- 
rant it, these mental hygiene societies should 
have the approval and the support of the 
public health workers. 

Mention has been made of specific control 
of one group of mental disea.ses, those caused 
by syphilis of the nervous system. There 
seems to be another specific preventive for 
some mental disorders, but it is one that 
presents all sorts of difficulties, not the least 
of which is our inadequate knowledge of it. 
This is the application of eugenics. While 
this question is one in which both public 
health and mental hygiene are greatly in- 
terested, it differs from the practices of each 
in that it is directed more toward those un- 
born than toward those born ; and it is such 
a complicated and controversial subject that 
it cannot be dealt with here. There is great 
need both for more .scientific knowledge and 
for more education of the public before we 
are in a position to apply effectively the 
principles of eugenics. 

It is possible that excejit in the case of 
hei-editary and syphilitic and other infectious 
di.seases, we shall never see specific causes 
and specific treatment and cures for many 
of the mental, nervous and emotional dis- 
orders, and any search or research for them 
is like chasing a will-of-the-wisp. In psycho- 
genic or mentally determined mental di- 
seases, we shall always have to depend on 
the difficult diffusion of mental hygiene 
teachings and principles and on the influence 
of individual practitioners and mental hy- 
gienists. 

In spite of these difficulties and these dif- 
ferences, there should nevertheless be a bet- 
ter understanding and collaboration between 
the program of public health and that of 
mental hygiene. 



THE NEWER KNOWLEDGE OF 
VITAMINS 

Victoria Carlsson 

Greensboro 

A deficiency disease, of whatever nature, 
causes distinctive functional disturbances 
which have their origin in morphologic 
changes in certain tissues. These are re- 
garded as primary effects. Various non- 
specific and secondary effects necessarily fol- 
low. 

Vitamins A, D, and E are soluble in fats 
and are associated with lipoid extracts of 
natural products. Vitamins B, C, riboflavin, 
and the antipellagra factor or factors, and 
certain others are soluble in water. There 
is at least one fat soluble factor not listed 
above, and several water soluble factors 
known to be indispensible for the rat or the 
chick which are not, apparently, essential 
for man. 

Vitamin A 

Vitamin A does not occur in the plant 
world, but its precursors, carotene and cryp- 
toxanthin are widely distributed. Carotene 
is one of the yellow pigments found in yel- 
low and green plants and was so named be- 
cause it w'as first isolated from carrots. It 
occurs in three forms. A, B, and Y-carotene. 
B-carotene has double the vitamin value of 
the other forms. The precursors carotene 
are also found in fish liver oils, milk, butter, 
eggs and liver in varying proportions. 

Vitamin A values are essential to the 
growth of the young and to nutrition and 
health at all ages. When the intake is in ex- 
cess of immediate need the body stores the 
surplus, so that a subsequent temporary defi- 
ciency of intake may show no effect. 

Dr. McCollum states that the pathological 
condition of vitamin A deficiency, or A-avi- 
taminosis, is the result of accumulation of 
keratinized epithelial cells in glands and 
their ducts, and in many organs. Wolbach'" 
has discussed the subject in detail. In the 
lungs, cyst formation and bronchial occlu- 
sion, with consequent bronchiectasis and 
atelectasis, have been observed in men and 
animals. In organs cysts are formed which 
are filled with a yellow cheesy mass of des- 

FrDin the Woman's College of the University of North Caro- 
lina. Read before the North Carolina Public Health Asso- 
ciation. Greensboro, May 1. 1939. 
1. Wolljach. Science. 8li:.5e9: J. A. M. A. SI :S28, 19.17. 



196 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



quamated keratinized cells. Higgins'-' found 
that urinary calculi occurred in 50 per cent 
of animals deficient in vitamin A, and he 
points out that keratinization of the epithe- 
lium of the genito-urinary tract, urinary in- 
fection, and alkalinuria are due to ammonia 
formation. On administration of vitamin A, 
the epithelial cells return to their normal 
form and function, the infection clears up, 
and the urine becomes acid. 

0'Conor'=" has pointed out the frequent oc- 
currence of calcium carbonate calculi in pa- 
tients on an alkaline diet in the treatment 
of ulcer, and states that the provision of 
abundant vitamin A is generally effective in 
preventing recurrence of these stones. 

During the last few years several clinical 
investigations have been published on the 
skin lesions which, according to some ob- 
servers, are the earliest evidences of vitamin 
A deficiency. Frazier and Hu'*' first pointed 
out that in this deficiency keratotic papules 
of varying size appear, distributed especially 
over the thighs, arms and shoulders, and 
arising from the pilosebaceous follicles. Mi- 
croscopically, the ducts are distended, and 
the openings are plugged with desquamated 
cornified epithelium. This eruption is rare 
in children, but rather common in adults, 
and when fully developed probably repre- 
sents late or severe deficiency. Dryness of 
the skin, according to these workers, pre- 
ceded the eye changes by several weeks. 

At the present particular interest centers 
upon vitamin A deficiency in relation to im- 
pairment of vision. It is believed that both 
in adults and in older children hemeralopia 
is one of the earliest manifestations of vita- 
min A deficiency. In general xerophthalmia 
and night blindness are present when the 
deficiency is of longer duration. Infection 
of the cornea is favored by the accumulation 
of keratinized cells and by lack of tears for 
washing the eye. and may lead to ulceration 
of the cornea. Night blindness is failure of 
vision in faint illumination. These patients 
respond well to administration of vitamin 
A.'-" 

The exact daily requirement of vitamin A 
has not been determined. Just as different 
foodstuffs vary in the amount of the vitamin 
they contain, so individuals may vary in their 
ability to absorb, store, convert, and destroy 

2. Hieeins. (', C. J. A. M. .\. IOt:U>!>6. 193.1. 
.1. OTontir. V. J.. J. A. yi. .\. nuMiSS. 193.1. 
I. Fraiier. B. N'. and Hu. C. K.. British M. J. i:ll3. l»3l. 
:*. Jeans. P. C. and Zentniire, Z.. J. A. M. A. 106:996. 1936; 
ibiil. 1011:131. ig3T. 



carotene and vitamin A. A number of esti- 
mates of daily human requirements for this 
factor are available. 

In the diets of nursery school children 
Rose, Robb. and Borgeson,"" found the daily 
supply of vitamin A at school as follows : 











Vttitx of 




Mfosurc 






Vitamin A 


Milk 


1 pt. 






1,000 


Cod Liver Oil 


1 tsp. 






2,000 


Butter 


1 t.sp. 






100 


Egg Yolk 


1 yolk 






825 


One Vegetable ricl 


1 








in \ itamin .\ 


2 tbsp. 


cai 


•rots 


1,000 



4,925 
If the home diet includes another pint of 
milk, another teaspoon of butter and another 
vegetable rich in vitamin A daily, the diet 
of a nursery school child would contain 6.000 
to 7,000 units of vitamin A per day. Stie- 
beling (1936) states that the daily require- 
ment of adults is from 4200-.56o6 Interna- 
tional Units. Growing children are allowed 
double the amount. The Committee of Nu- 
trition of the League of Nations (1936) sug- 
gests a daily intake of 8700 International 
Units for pregnant and nursing women. 
Vitamin A taken in large amounts is not 
toxic. 

Vitamin B 

The principal effects of vitamin B or thia- 
min deficiency are degeneration of the ner- 
vous system, cardiac enlargement and dys- 
function, edema, gastro-intestinal disturb- 
ances, muscular atrophy, and loss of appetite. 

Some of the nervous symptoms of thiamin 
deficiency are numbness and tingling sensa- 
tions, particularly affecting the fingers and 
usually associated with a gnawing pain 
which runs up the arm. especially at night. 

Cowgill" pointed out that conditions such 
as amebic dysentery, commonly found in 
beri-beri localities, may constitute the pre- 
cipitating cause of the deficiency disease. 
The inefficient utilization of thiamin due to 
loss in watery stools and to gastro-intestinal 
disturbances which interfere with the diges- 
tion and absorption of nutrients may be the 
cause. Strauss'^' has shown that this in- 
terference with absorption of thiamin is 
most frequently the cause of dietary defici- 
ency disea.ses, particularly pernicious anemia 
and related macrocytic and idiopathic hypo- 
chromic anemias, pellagra and "alcoholic" 

fi. Rose. M. S. : The Foundation iif Nutrition. 19JS. 

7. Cowgill: The Vitamin B Requirement of Man. 1991. 

8. Strauss, M. B.. J. A. M. A. 10t:l, 1914. 



April, 1940 



VITAMINS— CARLSSON 



197 



pregnancy, and other forms of polyneuritis 
in the temperate regions. 

Minot"" has reported cases of diabetes as- 
sociated with peripheral neuritis and achylia 
gastrica which responded to yeast therapy, 
and has raised the question whether achylia 
gastrica may not interfere with the utiliza- 
tion of both the anti-beri-beri and anti-pel- 
lagra vitamins. Many cases are recorded of 
the appearance of B avitaminosis associated 
with voluntary restriction of the diet as a 
result of digestive disturbances, or for thera- 
peutic measures, as in diabetes. Dr. Elsom""' 
studied a patient who had voluntary re- 
stricted his diet, whose symptoms resembled 
those of pernicious anemia. There was 
marked pallor, glossitis, and signs of pos- 
teriolateral sclerosis. The typical signs of 
pernicious-anemia achlorhydria and anemia 
were lacking. There was edema and low 
blood protein. Administration of a liver 
preparation adequate to produce remission 
of pernicious anemia caused only slight im- 
provement of the glossitis. On administra- 
tion of a concentrate of "B-complex" there 
was rapid improvement in respect to fatigue, 
anorexia, dyspepsia, paresthesia, edema, 
glossitis, scaling of the forearms and brittle- 
ness of the nails. Improvement began in two 
weeks and was complete in six. The pitting 
edema disappeared, and there was a simulta- 
neous rise in blood protein, although there 
was no increase in the protein content of the 
diet. 

Loss of appetite is one of the first observ- 
able symptoms of thiamin inadequacy. Cow- 
gill also noted loss of tone in the gastric 
musculature of thiamin-deficient dogs. 

The more recent studies"" have shown 
that thiamin deficiency is accompanied by a 
progressive diminution in carbohydrate tol- 
erance. Peters' "theory""-' is related specifi- 
cally to pyruvate oxidase in its aerobic re- 
action. This specific action manifests itself in 
two ways: (a) by increasing oxygen intake 
and (b) by decreasing markedly the pyru- 
vate formed by thiamin deficient brain tissue. 

McCollum states that at least four impor- 
tant factors may operate in determining the 
amount of thiamin that should be in the diet 
in order to satisfy the body's need. They 
are: (1) the absorptive ability of the ga.stro- 
intestinal tract, (2) the degree of thyroid 

9. Minot. r. R,. Ann. Int. Med. 3:216, 192fl. 

10. Elsnm, K. 0., Pennsylvania M. J. 87:87, 1983. 

11. Stcx'hr. Vitamin Forsch. 6:209. 1937. 

12. Peters, Biochem. J. 30:2206, 1936. 



activity, (3) the amount and quality of the 
fat in the diet, and (4) the amount of ribo- 
flavin in the diet. The first has already been 
discussed; the second is briefly reviewed by 
Carpenter and Shrapless"^', whose studies 
suggest that some factor present in yeast, 
which is lost when the yeast is anto-claved 
and which is not supplied by a vitamin B- 
containing extract, causes an increase in the 
iodine content and concentration of the thy- 
roid. Sure and Buchanan'"', have published 
results which show that in experimental hy- 
perthyroidism protection can be afforded by 
ingestion of large amounts of pure thiamin. 

The following are opinions (inadequately 
substantiated by facts) regarding thiamin 
needs. The Council on Pharmacy and Chem- 
istry of the A. M. A. ('36) gives as the mini- 
mum requirement for infants 50 Interna- 
tional Units, and for adults 200 International 
Units per day. Daniel and Munsell, ('37) 
give for adults 200-300 International Units 
per day; Rose, ('38) 400-500 International 
Units per day. 

The successful therapeutic use of thia- 
min"-" has been reported in: Neuritis asso- 
ciated with pregnancy ; heavy metal neuritis, 
such as lead, and arsenical neuritis occur- 
ring during intensive treatment for syphilis ; 
trigeminal neuritis ; certain so-called diabetic 
conditions; certain gastro-intestinal dis- 
orders; and lack of appetite. 

Vitamin G 

There is unanimity among investigators 
that pellagra is due to some dietary defici- 
ency which has been called Bo, P-P factor, 
and vitamin G. For some years it was gen- 
erally believed that a form of dermatitis in 
the rat caused by inadequate diet was ana- 
logous to human pellagra. This is now 
known to be a mistaken view. Maize, which 
has generally been abundant in the diet of 
the human pellagrin, prevents or cures the 
rat dermatitis. The factor necessary for the 
prevention of the rat dermatosis is now 
called vitamin B,,. The administration of 
liver, yeast, milk, lean meat, or wheat germ 
is curative in the human pellagra victims. 

Recent developments have indicated that 
nicotinic acid may prove to be a valuable 
therapeutic agent in the treatment of pel- 
lagra. Elvehjem, Madden, Strong and Wol- 

13. Carpenter and Shrapless. J. Nutrition, 13:235, 1937. 

14. Sure and Buclianan. Proc. Soc. Exper. Biol, and Med. 
33:775; J. Nutrition 12:513, 1937. 

15. Vorliaus. Am. J. Digest. Dis. and Nutrition. 3:915, 193T. 



198 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



ley""', have reported that nicotinic acid and 
nicotinic acid amide will cure black-tongue 
in dogs. Sebrell, Onstott, Fraser and Daft"' 
have confirmed Elvehjem's results and find 
that 6 mg. of nicotinic acid twice a week will 
prevent black tongue in a dog on a black- 
tongue producing diet during an experiment- 
al period of six months. 

A great number of research workers have 
administered nicotinic acid to pellagra cases. 
They noted rapid improvement in the mucous 
membrane lesions and in the erythematous 
skin lesions. They feel that nicotinic acid 
is either a pellagra-preventive vitamin or a 
provitamin, or that it is one of two or more 
substances necessary for the prevention of 
all the s\Tnptoms described as pellagra, or 
that it may be conjugated in the body into 
a more complex essential material. 

Sebrell writes: "Diets on which pellagra 
develop are also deficient in other respects. 
Attempts to prevent the disease by the wide 
spread use of nicotinic acid might allow 
symptoms of vitamin B, deficiency, protein 
deficiency, riboflavin deficiency or mineral 
deficiency to replace pellagra as a nutritional 
problem in this country." 

Therefore, although it may be desirable at 
some future time to attempt to prevent pel- 
lagra by the use of nicotinic acid mixed 
with some commonly used article of the 
Southern diet, the safest procedure at pres- 
ent is to continue vigorously our efforts to 
prevent disease by improving the diet, using 
nicotinic acid as individual circumstances in- 
dicate, and leaving the possibility of its un- 
controlled administration until additional in- 
formation is available. 

Vitamin C 

In humans a deficiency of ascorbic acid 
scarcely ever occurs unaccompanied by other 
dietary imbalance. This produces variability 
in the symptoms referable to scurvy, but in 
general the following are characteristic"' : 
The adult loses weight, is anemic, weak, and 
short of breath. The gums become swollen, 
bleed easily and frequently ulcerate. The 
teeth loosen and may drop out. Necrotic 
areas in the jaw bones may occur. Hemor- 
rhages in the mucous membranes and skin 
are characteristic. Blue-black spots develop 
in the skin after trivial injury, or they may 

16. Elvelijem. M.-idilcii. Strong, and Wollej', J. Biol. Chciii. 
123:137. l«3»<. 

17. Sebrell. W. H.. J. .\. M. A. 110:166.i. 1918. 
\s. Dalldorf. C. J. .\. M. .\. 111:1376. I93S. 



occur spontaneously. The ankles become ede- 
matous, and in some cases there develops a 
hard, board-like condition of the .skin and 
subcutaneous tissues. Nervous .symptoms of 
various types may appear. Children and in- 
fants are fretful, anemic, and without appe- 
tite. They fail to grow satisfactorily, and 
exhibit vague evidences of illness. 

Wolbach""' states that "The characteristic 
hemorrhages of scurvy are attributable to 
the inability of the body to produce inter- 
cellular material. The latter is necessary to 
the walls of the blood capillaries. It is the 
cementing substance which holds these cells 
together. This intercellular material consti- 
tutes the foundation of all fibrous structures, 
the matrices of bone, dentine, cartilage, and 
all non-epithelial cement substances, includ- 
ing that of vascular endothelium." 

The ability of human tissue to retain a.s- 
corbic acid depends in .some measure on fac- 
tors other than the amount of this sub.stance 
already in the body. Hawley'-'" and associ- 
ates found that normal persons .saturated 
with ascorbic acid excreted almo.st 100 per 
cent of daily test doses of pure vitamin C, 
when ammonium chloride was administered 
with it. However, the same dosage of vita- 
min, accompanied by .sodium carbonate, was 
followed by an excretion of only approxi- 
mately 50 per cent of ascorbic acid in the 
urine. 

Better retention of ascorbic acid was ob- 
tained when cabbage was fed to guinea pigs. 

Acetylsalicylic acid also caused increased 
excretion of ascorbic acid'-' -'-'. 

Chemical methods for assaying foods for 
ascorbic acid'-^' have been made fairly reli- 
able in recent years. The use of tests to esti- 
mate requirements for the vitamin, other 
than for the prevention of scurvy, are not 
sufficiently refined for universal acceptance. 

An average man would require 40-60 units 
of vitamin C per day, or one-half cup of 
orange juice. A child needs about 80 Sher- 
man units per day for safety """. 
Vita mill D 

Studies of recent years have shown beyond 
a doubt that there are several chemically 
distinct forms of vitamin D. Of the several 
forms which have been recognized to date, 

]•>. Wollwirh. J. .\. M. .\. ins:7. 19.17. 
■■". Ihiwlry. J.. Nutrition, 12:215. I93rt. 

-■I. DanieN .iiicl EverMtn. Proc. So.-. Expcr. Biol, and Med. 
.v.:*n. 1936. 

22. Bownmn and Muntwj-ler, Pr«c. Soc. Exper. Biol, and 
Med. 35:537. 1937. 

23. Mi-Tollum, E. v.: Tlie Kewcr Knowledge of Nutrition, 

1939. 



107 



April, 1940 



VITAMINS— CARLSSON 



1!.' 



two are known to be of prime importance in 
medicine. These are activated 7-dehydro- 
cholesterol and activated ergosterol. Ergo- 
sterol is a sterol which occurs in relative 
abundance in fungi such as ergot or yeast. 
Activated by exposure to ultra-violet rays 
and dissolved in oil it is called viosterol. The 
Germans call it vitamin D:;. Activated 7-de- 
hydro-cholesterol is cholesterol, the chief 
sterol of animal fats. Its active form thus 
comprises the vitamin D which is produced 
in the skin, fur or feathers of animals ex- 
posed to sunlight or other sources of ultra- 
violet rays. 

Individual variation in ability to utilize 
calcium and phosphorus of the diet without 
added vitamin D exists at all age periods. 
Some infants have poor calcium retention, 
and only a very few retain an ample amount 
without vitamin D. As the age increases 
more persons are able to retain adequate 
amounts of these minerals without vitamin 
D, but at all age periods some per.sons are 
found who are not able to do so. Cod liver 
oil, U. S. P. Grade, contains 85 International 
Units of vitamin D and 600 units of vitamin 
A per gram. Halibut oil contains 75-125 
times as much vitamin D as cod liver oil; 
tuna fish liver oil contains 40,000 Interna- 
tional Units per gram. 

The vitamin D requirement of a full term 
artificially fed baby is probably between .300 
to 400 units a day. Normal babies receiv- 
ing human milk require less vitamin D than 
babies receiving cow's milk. For children 
between infancy and adolescence a daily al- 
lowance of at least 750 cc. of milk with 300- 
400 units of vitamin D permits retention of 
calcium and phosphorus. 

For adolescents a need for vitamin D 
exists, but insufficient data are available to 
permit an estimate of the quantity required. 
300-400 units a day would be satisfactory'-^'. 
For adults the optimum amount of vitamin 
D, if a need exists, remains to be determined. 
During pregnancy and lactation the require- 
ment is greater than in any other period of 
life. A daily dosage of 800 units or more is 
suggested. 

The only method available to determine 
the vitamin D content of an oil is based upon 
observing the size of the dose necessary for 
the deposition of calcium salts in the bones 
of growing rachitic animals'--*'. It has been 

24. Jeans. P. C, J. A. M. A. lU:;uS. 1933. 



found that if a sample of cod liver oil and 
one of viosterol are assayed with young rats 
and then with rachitic chicks, about 100 
times as many rat units of the vitamin of 
cod liver oil is necessary to produce compar- 
able calcification in chick. This remarkable 
difference in the reaction of the rat and the 
bird affords a means of differentiating cer- 
tain of the different forms of vitamin D. 
Rat unit for rat unit, the vitamin of tuna 
fi.sh is only about one-seventh as potent for 
the chick as for the rat. Several careful in- 
vestigations with human infants have dem- 
onstrated that the latter reacts almost equal- 
ly well to the vitamin in cod liver and the 
viosterol. 

May Mellenby first demonstrated the im- 
portance of an adequate supply of vitamin 
D for the development of teeth with normal 
structure of enamel and dentine. She also 
showed by extensive studies on institutional 
children that the regular provision of vita- 
min D reduces the susceptibility of teeth to 
decay. Several investigators have confirmed 
her findings. Since the normal behavior of 
cartilage and normal content of phosphate 
in the body fluids are essential for the calci- 
fication of enamel and dentine, and both de- 
pend upon an adequate supply of vitamin D, 
the soundness of this view is apparent. The 
presence of pits and fissures in teeth, form- 
ing potential food traps, predisposes teeth to 
caries. Since the ameobla.sts are of epithelial 
origin, the significance of vitamin A, so 
necessary to prevent keratinization of this 
type of cell, is also apparent for the forma- 
tion of normal enamel. 

Richardson's study'-'' on the effect of vio- 
sterol during pregnancy and upon the dura- 
tion of labor in primiparae is of great in- 
terest. Of the 300 cases studied, 201 were 
given viosterol during pregnancy. The length 
of time of labor was reduced to almost one- 
half, and the loss of blood was less in women 
treated with viosterol. 

Wilder and Howell'-'' point out that the 
majority of cases of parathyroid enlarge- 
ment occur in the northern part of the 
United States. Several investigators have 
described the extraordinary enlargement of 
parathyroids in chickens deprived of vita- 
min D. This condition is rare in the south, 
whereas it occurs frequently in the north. 

;.i. Iiich:in|.ion, O. C, Ulinois Meil. J. 05:367. 1934. 
20. Wilder and Howell, J. .\. .M. A. 100:427. 1936. 



JOO 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



O 



§■0 






5= S 



•2.. 



?£( 












2 TO 4) _ _ 

3 m o m ~ 









=> 5 



=1- 



5 sS— 
E = = !=■; 

4. ^ ~ E — 
- = S = >.2 . 

<= « - O O C-r 

c c < > 

330 w £, 



"Sec. '^ 



t_jc5op<: 






5 = g^S° ^-='^S-gi.s-£,-£ 



, Mi 



3 V UlSli »^ 


















o o — «— ; 



"■■=:; ot;* 1. s 5 .-5 4 






c-c-^ 



: c = S = ' 









'C&^i 



c c cJ 



SS Soog> 
ai zzz" 



z°„ 



M r £ = S 



£ c 5 e^ 






2: o -"S 
■85.= 






m^ 



\xun 



'in! :-3, 
= i = 



£3 

O V 

C « 1- 

1 



do 






OS* 






i5"f ■: = I = § 
lililflll 






ill ill I si 






E-i 



: a ». ■- 

3.2 5'r:3 i 



^ Z' 

•J g 






."H « C " « X CO = 






C.C 3 

' = ! 

O 3^ " 






sis 

o rt - 



Z£c 



Sum 



» isE ."c 



3 - 5^ T V 



:=!. 



_ - O 

&i5 



!SS?= v'ScS 



IT « a; ^ ^ C 
SJ T = • 

■f- . i: C »- - t- I- 
S1=~ sJ; u 4: c tt 



3^.3 B 
ESSE 



CM ° 



Z ff J.- = o z « 
= ^5i:Z =4.. 



= ». 3 41 

*-- — c — 

i||g|=|f= 






— s — 'X, :. 



feo 



c c- ee 



s is" 






— - s = 
u c — ■:; S 



?^'^e£ = ! 









!l -V. W ^ S, 

s*^ e fl, t ^ 






.^■?s 



c -.^ 






?T ;:.= ?. 



"1 

si 



.,«' 

>; 



k4 «C 



j= c : 






SsiEffiiii 



z . « u 

Sill 



April, 1940 



DIABETIC COMA— WHITAKER AND TURRENTINE 



207 



Vitamin K 

In 1935 Dam of Copenhagen observed that 
newly hatched chicks maintained on a diet 
which was deficient in certain fat sokible 
material, but otherwise adequate, suffered 
fatal hemorrhages into subcutaneous tissues. 
This condition was controlled by administra- 
tion of nonsaponifiable, nonsterol fraction of 
hog liver fat, or by feeding alfalfa'-". 

Vitamin K occurs in alfalfa, kale, spinach, 
dried carrot tops, chestnut leaves, tomatoes 
and oat sprouts, soy bean oil and vegetable 
oils, but is not found in significant amounts 
in fish liver oils. 

Very little is known of its physical and 
chemical properties except that it is heat 
stable, fat soluble and readily destroyed by 
alkalis. 

It is used clinically in certain diseases 
where there is a deficiency of prothrombine 
in plasma. This deficiency may be due to 
failure of absorption of this vitamin when 
bile is e.\cluded from the intestinal tract, or 
when secretion of bile salts is reduced. In 
pre-operative cases it may be given in some 
concentrated form to rai.se the prothrombine 
of the plasma. 

In the past year the sale of vitamins in- 
crea.sed five-fold. Although most vitamins 
are too expensive at present to be added 
economically to the diet, science has laid a 
foundation for opening this field in a big 
business scale. Not only vitamins but min- 
erals like iron, calcium and iodine can be 
added to this business. 

Adding excessive amounts of certain vita- 
mins or minerals to the diet may be danger- 
ous, because other latent deficiencies of per- 
haps unknown kinds may result. Today we 
regard an adequate diet as composed quali- 
tatively of many chemically di-screte compo- 
nents provided in such state of combination 
that they are utilized efficiently. An adequate 
diet can be encouraged by stressing the need 
for protective foods, such as milk, meat, 
eggs, vegetables and fruits in the diet. 

27. Snell, A. M., J. A. M. A. I12;H57. 10.19. 



Electrocardiograms. — The real reason for taking 
an electrocardiogram on every patient with a cardiac 
arrhythmia is so that after one has studied the 
records of a large series of cases, he may under- 
stand the clinical manifestations of cardiac irregu- 
larities so well that he is able to recognize the type 
of arrhythmia without the electrocardiogram. — 
Francis W. Peabody: Doctor and Patient, New York, 
The Macmillan Co., 1939. 



DIABETIC COMA 

Paul F. Whitaker, M.D. 
and 

KiLBY P. TURRENTINE, M.D. 
KiNSTON 

Diabetic coma is probably the most spec- 
tacular emergency that we are called on to 
deal with in medical practice. Only those 
practitioners who have directed the treat- 
ment of diabetic coma to a successful con- 
clusion can realize the real satisfaction that 
this gives. Our experience in the manage- 
ment of diabetic coma consists of sixteen 
cases which have occurred in our practice 
in the last fifteen years. Most of these cases 
were referred to us by other physicians and 
were managed on our medical service at 
Memorial General Hospital in Kinston. Out 
of the sixteen cases treated three deaths 
occurred. We feel now that two of these 
were inadequately treated, and in the light 
of our present experience we feel that they 
could probably have been saved by larger 
doses of insulin. 

Pathologic Physiology 

The pancreatic hormone insulin is neces- 
sary for the utilization of all foods, protein 
and fat as well as carbohydrate. In the ab- 
sence of insulin all starch and sugar ingested 
appears in the urine as glucose. Moreover, 
from 45 to 58 per cent of the protein content 
of food and also the body protein which is 
utilized to maintain life during periods of 
starvation consists of glucose or compounds 
similar to glucose. In the absence of insulin 
this glucose derived from protein also occurs 
in the urine. Lastly, when glucose is not 
utilized by the body, the oxidation of both 
ingested fat and body fat is not complete, 
and instead of being converted into carbon 
dioxide and water, the oxidative process is 
halted before this point is reached and the 
fat yields various toxic acid substances such 
as beta-hydroxybutyric acid, aceto-acetic 
acid, and acetone. These are known collec- 
tively as ketone or acetone bodies. Ketone 
bodies are probably formed in the liver and 
are then excreted in the urine. Before being 
excreted in the urine they are neutralized by 
the alkalis in the tissues and the blood, con- 
sisting of sodium bicarbonate and various 



Kfad before the Robeson County Medical Society. Lumberton, 
.N'ovember s, 19S9. 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



salts of potassium, calcium and magnesium. 
Small amounts of ketone bodies are easily 
tolerated, but the formation of large 
amounts, such as occurs in severe diabetic 
acidosis, results in the continuous excretion 
of sodium salts and other base in the urine. 
A very small fraction of the acid substance 
mav be neutralized by ammonia and excreted 
in the urine in the form of ammonium salts; 
but it is chiefly the sodium and other bases 
that are involved. At first only the body 
tissues are affected by this loss of base, and 
the blood chemistry remains unchanged. 
Finally, however, after the supply of base 
in the tissue is exhausted, the sodium con- 
tent of the blood is drawn on to maintain 
neutrality. In addition, both the neutralized 
ketone bodies and sugar must be in solution 
before the kidneys can excrete them, and as 
a result there is a tremendous loss of water 
in their excretion. Associated with the loss 
of water there is a loss of chlorides. The 
reason for this is not understood. After all 
compen-sating mechanisms fail, the alkalinity 
of the blood is decreased and eventually the 
blood becomes slightly acid in reaction. It 
is not entirely understood, nor for practical 
purposes is it necessary to understand, how 
changes in the blood produce the character- 
istic s\-mptoms of diabetic acidosis and coma. 
The extent of these chemical changes can 
be determined to a considerable degree by 
analyzing the blood for its carbon dioxide 
combining power. This is obvious for the 
reason that if the sodium of the blood has 
been lost through the urine in the form of 
sodium salts or has been held in combination 
with strongly acid ketone bodies, it is unable 
to combine with carbon dioxide and its car- 
bon dioxide combining power is reduced. 

This test is important because a sharp 
reduction in the carbon dioxide combining 
power of the blood is tolerated poorly, and 
is practically always a sign of impending 
trouble. In the diagnosis and treatment of 
coma it is more important than blood sugar 
determinations, which are usually over-em- 
phasized. It is true that if acidosis occurs 
in diabetes the blood sugar is almost in- 
variably increased, but on the other hand 
the level of the blood sugar is not always 
indicative of the severity of the acidosis. 
For example, a patient in profound coma 
may not have an unusually high blood sugar ; 
and on the other hand a patient may have a 



very high blood sugar without coma or even 
acidosis. 

Etiology 
Diabetic acidosis and coma are prevent- 
able, and when they do occur are usually the 
result of either ignorance or neglect. Their 
complications occur in severe diabetic pa- 
tients as a natural consequence of the disease 
when treatment is inadequate, or as the re- 
sult of some other disease, accident, or strain 
imposed on the patient with diabetes. In 
mild diabetics they practically never occur 
save in the presence of some associated di- 
sease or complication. 

Acute infection — particularly acute colds 

extraction of teeth, fractures of bones, 

prolonged physical or mental strain, and 
hyperthyroidism are frequent factors that 
bring on acidosis. Breaking the diet, insuf- 
ficient amounts of insulin, or omission of 
insulin are also common causes. Often an 
otherwise well instructed diabetic will omit 
his insulin when his appetite fails from 
some acute infection or other cause, for fear 
of an insulin reaction. He does not realize 
that as soon as ingestion of food ceases he 
begins to catabolyze his own tissues. This 
food cannot be utilized in the absence of 
glucose and, consisting largely of fat, it 
yields large amounts of ketone bodies. In 
addition, in the presence of infection and 
other complications, the efficiency of insulin 
is decreased. The patient is, therefore, omit- 
ting insulin at a time when he needs it most, 
and severe acidosis with subsequent coma 
may develop within a few hours. 
Prevention 
At this point, before discussing the diag- 
nosis and treatment of coma, it might be 
well to outline briefly measures that will 
prevent it. These measures have been out- 
lined and used by Dr. Woodyatt of Chicago 
for more than eighteen years, and are tried 
and proven. They have been used in the 
practice of the writer for more than twelve 
years. Knowledge by the patient that he is 
"a candidate for acidosis and coma in the 
presence of a cold, accident, or any acute in- 
fection is essential for him to carry out the 
preventive steps, and it is the duty of the 
physician to instil this knowledge into his 
patient. 

When a cold, for example, has developed, 
the patient should promptly divide the day 
into Si.x-hour periods. At 6 a. m., 12 noon. 



April, I'.Uil 



DIABETIC COMA-VVHITAKEK ANU TURRENTINE 



207 



6 p. m. and 12 midnight, he should empty 
the bladder, test the urine for sugar and 
ketone bodies, give a dose of insulin and a 
standard feeding. A standard feeding con- 
sists of 400 cc. (2 glasses) of milk, or 300 
cc. of orange juice. 

The first insulin dose should consist of one 
quarter of the patient's regular dose for 
twent.v-four hours, plus 5 units. The second 
dose should have 5 more units than the fir.st 
if acid is still present. The following doses 
should be increased by 5 units each dose 
until diacetic acid is absent, and later on the 
dosage from period to period should be ad- 
justed as required to control glycosuria and 
insulin reaction. If the patient is on prota- 
mine insulin, the protamine insulin dosage 
should be continued, and the emergency pro- 
gram superimposed on it. 

If early clinical symptoms of actual acid- 
osis are present the program is the same 
except that feedings are omitted until the 
symptoms have disappeared. In addition the 
first dose of insulin should be large enough 
to cause disappearance of the .symptoms in 
the first six hours. The do.se should be ' U 
to 1 unit per kilo body weight, or even more. 
It is better to give too much than to give 
too little and risk coma, which is much more 
dangerous than an insulin reaction. When 
symptoms have ceased insulin reactions can 
be prevented by frequent hourly feedings of 
50 to 100 grams of orange juice. As long as 
sugar appears in the urine there is no danger 
of hypoglycemic reaction, but it is well to 
have the patient empty his bladder each time 
the urine is examined, since residual urine 
may be misleading. 

As soon as the symptoms of acid intoxi- 
cation have subsided the case becomes one 
of ketosis without clinical symptoms, and the 
procedure of six hour examinations and in- 
sulin doses as needed .should be resumed. 

Symptoms and Diagnonis of Diuhctic Coma 

The initial symptoms of coma are vague 
and deceptive. It is, therefore, well to sus- 
pect acidosis in any case of diabetes when- 
ever any unusual sign or symptom develops. 
Weakness, headache, thirst, loss of appetite, 
vomiting, lassitude, drowsiness, and pain in 
the back, legs, and abdomen are among the 
common early symptoms. Later dehydra- 
tion, deep breathing, somnolence, and coma 
develop. Eventually the breathing becomes 
shallow and irregular. 



The diagnosis of diabetic acidosis an 
coma should be suspected at the bedside anc 
should be verified by finding in the urine a 
large amount of sugar and a strongly posi- 
tive ferric chloride test for diacetic acid. 
The blood sugar is increased and the carbon 
dioxide combining power is reduced. As has 
already been stated, elevation of the blood 
sugar may not parallel the clinical condition 
of the patient, but usually the carbon dioxide 
combining power shows some parallelism to 
the patient's condition. Definite symptoms 
do not appear until the carbon dioxide com- 
bining power has dropped below 40 volumes 
per cent and may not appear until it has de- 
creased below 30 volumes per cent. Below 
20 volumes per cent the symptoms are usual- 
ly marked. 

Albumin and casts in the urine and eleva- 
tion of blood urea are usually pre.sent in 
diabetic acidosis and should not be mislead- 
ing. Leukocytosis often occurs. 

Treatment 

The treatment of diabetic coma calls for 
the prompt administration of insulin and 
fluids to restore the water balance of the de- 
hydrated patient. It should be emphasized 
that there are no hard and fast rules for its 
treatment, and that each case should be con- 
sidered as an individual problem. Neverthe- 
less, it is well to have in mind some standard 
line of procedure to follow in the manage- 
ment of these cases, and to modify it as 
necessary for each individual case. It is 
highly desirable to have these patients in a 
hospital for treatment in order that proper 
laboratory observations can be made fre- 
quently. Promptness is important, and if 
the patient is seen at home insulin should 
be promptly administered before moving 
him. The earlier the treatment is started, 
the better the prognosis ; and the longer it is 
delayed, the more grave the prognosis. 

Diabetic coma and shock have many points 
of similarity, and the adjuncts to treatment 
in both are much the .same. The bed should 
be warmed before receiving the patient, and 
the patient should be kept warm by hot 
water bottles. Unless the patient is mori- 
bund, ga.stric lavage should be done with a 
warm solution. Five per cent solution sodium 
bicarbonate is satisfactory, and after remov- 
ing the gastric contents 250 to 500 cc. of the 
solution may be left in the stomach. Follow- 
ing this a cleansing enema is given routinely. 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



g The dosage of insulin is that amount 
vvhich will accomplish the purpose for which 
it is given, and it will vary according to the 
age of the patient, the severity- and duration 
of the acidosis, the previous dosage of in- 
sulin and, to some extent, according to the 
usual dosage of insulin. For example, a pa- 
tient taking 40 units of insulin a day will 
obviously need a larger dose than a patient 
who has never taken insulin. Generally 
speaking we give large doses at frequent in- 
tervals — from 50 to 100 units, usually the 
latter, every thirty minutes to an hour until 
improvement is noted. We prefer to risk 
overdose and a resulting insulin shock than 
underdose and death by coma. As soon as 
the patient is able to retain fluid by mouth, 
orange juice, ginger ale, sweetened coffee 
and tea should be given frequently to coun- 
teract the insulin. If it is felt that the in- 
sulin is not being absorbed, it may be given 
intravenously instead of subcutaneously. 

Treatment is greatly facilitated by the 
frequent determination of blood chemistry, 
but can be carried out with hourly urinalyses 
as the only guide to treatment. Twenty or 
30 units can be given when the urine turns 
red with Benedict's Solution, 15 units when 
orange and 5 or 10 units when green. 

Patients in diabetic coma are almost in- 
variably dehydrated, and quick restoration 
of body fluids is necessary. We usually give 
an initial intravenous administration of 1000 
to .3000 cc. of normal saline and continue it 
by hypodermoclysis. The total amount per 
day may be as high as 7000 cc. 

It is common practice to give glucose in- 
travenously at the beginning of coma. We 
do not see the necessity for this, because 
the patient is already pouring out enormous 
amounts of glucose in the urine, and further- 
more, its administration interferes with the 
evaluation of the treatment. We believe this 
practical consideration carries more weight 
than any theoretical benefit that might ensue 
from increasing the amount of utilizable car- 
bohydrate. 

The blood sugar may often drop before 
the carbon dioxide combining power rises. 
If the lag in recovery of the carbon dioxide 
combining power is too great, then 250 to 
500 cc. of 3 per cent sodium bicarbonate 
.solution can be given intravenously. Ulti- 
mately the carbon dioxide combining power 
returns to normal as a result of liberated 
bases previously combined with ketone 



bodies. Joslin does not recommend the use 
of alkalis. Large amounts are definitely con- 
traindicated for reason of the fact that they 
will cause alkalosis, but the judicious use of 
small amounts is, in our opinion, indicated 
at times. 

Circulatory failure is indicated by falling 
blood pressure and at times by anuria. The 
cause of death may possibly be due to the 
toxic action of ketone bodies on the myo- 
cardium, but it seems more reasonable to 
a.ssume that death occurs, as in shock, from 
insufficient volume of circulatory fluid. This 
is best corrected by fluids rather than cardiac 
stimulants. 

In conclusion it may be said that the prog- 
nosis depends on many factors — the age of 
the patient, complications, and the length, 
degree and duration of coma. Coma is pre- 
ventable and should be prevented. WTien it 
does develop, if it is detected early, the life 
of the patient can usually be .saved. 



PROPHYLACTIC MEASURES OF 

PROVEN VALUE IN SOME OF THE 

INFECTIOUS DISEASES 

J. Bl'REN SlDBURY, M.D. 
WiLMINGTOX 

The progress that has been made in pre- 
ventive medicine in the past twenty-five 
years has been phenomenal. The span of 
life has been lengthened by ten to fifteen 
years, and the control of infectious diseases 
has been gratifying to the medical profession 
and comforting to the laity. Many heart- 
aches and sorrows have been spared to mil- 
lions of our population by the prevention of 
disease and death. 

Briefly I wish to call your attention to 
those measures which are at our command, 
with a desire to encourage their more gen- 
eral use. 

Small Pox 

There was a time in the memory of many 
of us when small po.x was a menace to our 
population. It was Jenner who gave to us 
the .simple procedure of small pox vaccina- 
tion, which has so nearly eliminated this 
disease that our Health Department does not 
now class it as one of the quarantinable di- 
seases. We know that small pox can be 



Read before the .<se»-tion on Public Health ami Education. 
Medical Society of the State of North Carolina, Benuuda 
Cruis«. Mar 10, l«39. 



April, 1940 



PROPHYLACTIC MEASURES— SIDBURY 



207 



eliminated entirely by vaccination. By some 
it is felt that vaccination between six and 
twelve months is less dangerous and more 
desirable than at six years. 

Typhoid Fever 

During the War between the States ty- 
phoid fever killed more men than died on 
the battle field. This was true of all wars 
until the World War, when all soldiers were 
given typhoid vaccination before going in 
the trenches. As a result of this, typhoid 
and paratyphoid fever were a negligible fac- 
tor in the World War. Having had this 
practical demonstration of the effectiveness 
of typhoid vaccination, we should have as 
many as possible of our population vacci- 
nated every three years for four or five 
series, and thereafter when there is any defi- 
nite exposure. Too often we wait for an 
epidemic before urging typhoid vaccination. 
Each year not later than April or May the 
local health officer and the State Board of 
Health should bring this to the attention of 
the public by means of the radio and press. 
Our people expect us to keep them informed 
along these lines. 

Scarlet Fever 

The prophylactic measures used in scarlet 
fever have not been as successful nor as 
widely used as some of the other remedies 
we will discuss. One of those used is scarlet 
fever toxin which is given in five graduated 
doses. The number of doses has been one 
deterring factor, and many hold that all that 
is accomplished by these injections is the 
prevention of the rash in scarlet fever, which 
creates a distinct obstacle in the diagnosis 
of the disease. The duration of this immuni- 
ty is short, probably one year. 

Most of us found that the administration 
of scarlet fever antitoxin was accompanied 
by many cases of serum sickness. Often the 
prophylactically treated case was sicker than 
the patient with scarlet fever. 

As a result of the relatively .short duration 
of immunity and the frequent occurrence of 
serum sickness this prophylactic procedui'e 
has not been extensively used. Too, the sus- 
ceptibility to scarlet fever is much less than 
to measles and whooping cough — probably 
less than 15 per cent of the population being 
susceptible to scarlet fever. However I do 
advise a Dick test on all student nurses and 



interns, especially those who have to woi 
in hospitals for contagious disease. 

Diphtheria 

For about twenty-five years now the medi- 
cal profession, led by the late Dr. W. H. 
Park, has been at work on the prophylactic 
treatment of diphtheria. Probably more 
intensive educational campaigns have been 
waged in New York City than in any other 
l)lace in this country. When we see that the 
deaths last year from diphtheria in New 
York City, with a population of over seven 
million, were only 27, while our state with 
half that population had 188 deaths, we are 
convinced that diphtheria is a problem that 
requires our earnest support. 

Thanks to our able senator. Dr. T. W. M. 
Long, we now have a law which requires im- 
munization against diphtheria of all children 
between the ages of six months and six 
years. A certificate must now be presented 
as a requisite to entering the public schools 
of North Carolina. 

At first toxin-anti-toxin was used in three 
to five doses one week apart. Later toxoid 
in two or three do-ses, and still later alum 
precipitated toxoid in one do.se and then two 
doses six to eight weeks apart, were advo- 
cated. It is felt that one dose of alum pre- 
cipitated toxoid will immunize 85 per cent 
of the cases and two doses will immunize 95 
per cent. For this reason two doses are 
given. It is advisable to have Shick tests 
done each year for five or six years to detect 
the small per cent who lose their immunity. 

If the contacts can be seen daily and cul- 
tures obtained, it is not advisable to give 
antitoxin prophylactically. If such is not 
possible, I feel that we should play safe and 
give 1000 to 1500 units of diphtheria anti- 
toxin to members of a family which has a 
definite clinical case. 

Tetanus 

The question when to give tetanus anti- 
toxin in abrasions and puncture wounds is 
ever being asked the medical man as well as 
the surgeon. No one knows definitely how 
to answer this question, but in doubtful cases 
we have to play safe and give the antitoxin. 
We know, or believe, that much tetanus an- 
titoxin is given unnecessarily, but we do 
not know how, safely, to avoid this. Recently, 
however, it has been found that tetanus 
toxoid can help solve this difficult problem. 



NORTH CAROLINA MEDUAI. JOURNAL 



April, I'.I-IU 



g I two doses of each of tetanus toxoid 

ire given at ' three month intervals, 

the tetar- to 1 concentration in the 

blood ' 7^ '^ V point not quite suffi- 

If rom the disease ; but 

i tc. of tetanus toxoid is 

i;iven the tetanus antitoxin in the blood will 
immediately increase and rise to a higher 
level than when 1500 units of tetanus anti- 
toxin is given and this level is sustained in 
the blood stream longer than when tetanus 
antitoxin is given. 

A routine which is practical would be to 
give 1 cc. of tetanus toxoid at the same time 
that diphtheria toxoid is given. Give 2 doses 
at two month intervals. Later, if the child 
gets an injury, a third dose of tetanus toxoid 
may be given instead of tetanus antitoxin. 
The dangers of horse -serum reactions are 
thereby eliminated. 

A measure which I have routinely adopted 
is to give all ])atients with eczema, hayfever 
and asthma two injections of tetanus toxoid 
at two or three month intervals. If they get 
a rusty nail puncture later, they are given 
the third dose of tetanus toxoid, 1 cc, and 
no antitoxin is given. 

Wlioopino Couf/h 

I know that all of you who have done 
much general practice have given whooping 
cough vaccine. I have probably given a bar- 
rel of the vaccine originally put out by our 
State Board of Health. I do not believe it 
benefited 10 per cent, if any of the cases. It 
was often given for the lack of something 
better to do, when doing nothing would have 
been better practice. 

Sauer'.s whooping cough vaccine is of defi- 
nite value as a prophylactic remedy, but not 
as a therapeutic remedy. Dr. Sauer advi.ses 
that it should be given three to four months 
before exposure if beneficial results are to 
be expected. 

In the past four years I have given 290 
infants and children Sauer's whooping cough 
vaccine as a routine prophylactic measure. 
Of this number seven cases developed per- 
tussis either while being treated or within 
two weeks after treatment was finished. 
Two children developed light cases three 
years later. 

In one family of four children, ages four, 
three, two years, and five weeks, the oldest 
child was treated at ten months with Sauer's 



whooping cough vaccine. One month ago the 
three and t\\o year old sisters developed very 
definite cases of whooping cough with all the 
typical signs, cough and whooping, and 
vomiting. The older child escaped. The five 
weeks old infant was given hyperimmune 
serum after being exposed to his sisters for 
ten days. Three doses of 10 cc. each were 
given three days apart. He was beginning to 
cough when the serum was started. At the 
end of one week he had stopped coughing 
and escaped completely. 

Another four weeks old baby was exposed 
in his own home to his sister and aunt who 
had whooping cough. He had been coughing 
for one week when .serum was given, and 
two do.ses of 10 cc. of hyperimmune serum 
at three day intervals satisfactorily aborted 
his case. 

A third patient, who had had severe per- 
tu.ssis for three weeks, was given four doses 
of 12, 20, 30, and 20 cc. at three day inter- 
vals. He was very little improved at the end 
of four weeks. Because of his anemia he 
was given two transfusions which could well 
have explained the slight improvement he 
made. At the end of four weeks he still had 
bad and rather frequent paroxysms. This 
ca.se showed a blood count on admission on 
February 25, 1939, of Hgb. 65 per cent, RBC 
4,000,000, WBC 57,850, Polys 76, Lymphs 
22. Monos 2. On March 4 the blood examina- 
tion after two transfusions showed: Hgb. 
100 per cent, RBC 5,200,000, WBC 29,000, 
Polys 47, Lymphs 50, Monos 2, Eosinophils 1. 

A fourth case was an infant of three 
months who had had whooping cough for 
two weeks when the hyperimmune whooping 
cough serum was given. She received three 
doses of 10 cc. each at two day intervals. 
Her blood e.xamination on admission showed : 
Hgb. 60 per cent, WBC 31,030, RBC 3,375,- 
000, Polys 16, Lymphs 84. Because of her 
anemia she was given two small transfusions 
on successive days in conjunction with the 
hyperimmune serum. Her last dose of hy- 
perimmune .serum was given at the end of 
the third week. Her blood examination fol- 
lowing the transfusions and serum .showed: 
Hgb. 85 per cent, RBC 4,150.000, WBC 25,- 
SGO, Polys 20, Lymphs 80. A very definite 
but not spectacular response to the serum 
was obtained in her case. 

In three of these four cases a definite re- 
sponse was obtained. Those receiving the 



April, lOJO 



PROPHYLACTIC MEASURES— SIDBURY 



207 



serum early responded more promptly. The 
other case was too late in the disease to ex- 
pect much result. On account of the .severity 
of his case he was given large doses. 

The hyperimmune whooping cough serum 
is otherwise known as Lyophile "Pertussis 
Immune" serum. "This .serum is prepared 
by pooling the bloods of a number of healthy 
adults who have had whooping cough in 
childhood and whose protective substances 
have been 'fortified' by repeated courses of 
Sauer's vaccine. The technique of collection 
and preservation fulfills all the requirements 
of the United States Public Health Service." 
This product may be obtained from the Phil- 
adelphia Serum Exchange, Children's Hos- 
pital, 1740 Bainbridge Street, Philadelphia, 
Pa. It may be of value in the treatment of 
whooping cough if given early in the disease. 
Twenty to thirty cc. may be given at one 
dose, and two or three doses may be given. 

Rabies Vaccine 

Rabies vaccine, of course, should be given 

as early after the bite of a rabid animal as 

possible. A delay of two or three days is 

if the bite is not located on the head or 

ce. The original 21 day treatment has 



been supplanted by the 14 day treatment — 
a saving of no little consideration. 

Meanles 

In 1927 a number of high .school boys who 
had recently had measles were bled and their 
serum was given to infants and children who 
had been exposed to measles. It was found 
that if as much as 5 or 10 cc. of recently 
convalescent serum was given before the 
seventh day of exposure measles could be 
prevented in the great majority of cases. 
Since then this idea of convalescent serum 
or whole blood has been extensively used 
to prevent measles and other infectious di- 
seases, especially in feeble infants. Dr. Mc- 
Khann, of Harvard, has perfected a com- 
mercial product, "Immuno-Globulin", which 
accomplishes the same protection with much 
less volume in dosage. Two cc. of Immuno- 
Globulin repeated in three or four days 
usually protects, if given within seven days 
from the time of exposure. 

The following charts show the results I 
have obtained in the past ten years with the 
three methods of procedure. The whole blood 
injections have some disadvantages, but in 
my hands have yielded the highest percent- 
ages of protection. 



CONVALESCENT SERUM 



Year 


.Vo. Cases 


Exjuisffl 


Ami. Oivii 


Complrtelii 
Protected 


Parliatlij 
Protected' 


.Vol 
Prulcrted 


1928 
1928 


69 
15 


1-7 days 
8-12 days 


5-10 cc. 
5-10 cc. 


4.3 

8 


25 

7 


1 



TOTAL 


84 




1 60. 7'/^ 


38.1% 


1.2'; 



IMMUNO-GLOBULIN 



1938 
1938 


1 


1-7 days 
8-12 days 


2cc. 
2cc. 


63 
1 


32 
2 


7 
2 


TOTAL 


97 






55.7 '/r 


35% 1 9.3'/c 



WHOLE BLOOD INJECTIONS 



1933 


107 


1-7 days 


20-40 cc. 


60 


43 


4 




1933 


24 


8-12 days 


20-40 cc. 


9 


11 


4 




1938 


32 


1-7 days 


20-40 ce. 


24 


8 







1938 


1 


8-12 days 


20-40 cc. 








1 





SUMMARY 



Whole 
Blood 


164 


1-12 days 


20-40 ec. 


56.7% 


37.8% 


5.5% 


Convalescent 
Spriiin 


84 


1-12 days 


5-10 cc. 


60.7-;;, 


38.K/n 


1.2% 


Immuno- 
Globulin 


97 


1-12 days 


2ce. 


55.7-:-, 


35. % 


9.3% 


TOTAL 


346 


1 1 57.4% 


37.1% 


6.5% 



*Very slight rash, no temperature. 



208 



NORTH CAROLINA MEDICAL JOURNAL 



April, 1940 



DISTRIBUTION OF SYPHILIS AMONG 

THE PATIENTS IN PEDIATRICS AND 

OBSTETRICAL PRACTICE 

D. E. Robinson, M.D. 

W. B. Perry, M.D.* 
H. R. Germer, M.D., 

G. M. Leiby, M.D.t 

For the past three years the campaign 
against syphilis in the United States has 
been gaining momentum. Morbidity statis- 
tics indicate that the emphasis and the 
energy being expended in this direction are 
well justified. The attitude and policy of the 
profession has been one of constant aware- 
ness of the true seriousness of the situation. 
It has attempted to avoid exaggeration of 
the facts, and hysterical propaganda. It has 
striven against indifference and the assump- 
tion that, although syphilis may be preva- 
lent, it does not occur in private practice. 

Congenital syphilis, like many other prob- 
lems concerning the infant, calls for the co- 
operation of the obstetrician and the pedia- 
trician. It is this territory which we have 
in common, the pregnant woman and her 
infant, that we have attempted to explore. 
Two surveys have been made. Members of 
the State Pediatric Society contributed to 
one. This probably gives a fair picture of 
the facts as experienced in private pediatric 
practice. Another study conducted through 
the cooperation of Dr. R. L. Carlton and Dr. 
J. R. Hege presents the problem in an in- 
dustrial community of North Carolina. To 
them and to the obstetricians and pedia- 
tricians we wish to express our sincere ap- 
preciation for their help with these studies. 

For a moment we shall consider the results 
of the first survey. The purpose was to de- 
termine the Wassermann status of the group 
studied. There were 514 infants under 12 
months of age and their mothers. Five hun- 
dred and nine were white ; five were colored. 
Among the infants 248 were males, 201 were 
females; in 60 sex was not reported. Four 
hundred and ninety had no Wasserman test; 
twenty-four had tests. Nineteen were nega- 
tive; four were positive; one was doubtful. 
Three infants with positives were tested at 

•.■ipoiial roiisultiiiil. liiilpd Stales Public Health Scrvirc. 
rConsiiltant. A'eiiereal Disease Control. N. C. State BoanI "f 

Health; aiirl Cliniial In.ilruitor in Sj philology. Duke L'lii 

\ersity. Durham. N. C. 

("Iiainnan"'* Address- to the Section on Pediatric*?, Medical 
Society of the State of North Carolina, Bermuda Meeting. 
.May II), 1939. 



two months; one at one month. Two mothers 
with positive infants had had tests which 
were positive in the third trimester and no 
treatment. One had a positive test in the 
first trimester and three intravenous treat- 
ments. One had had no test. 

Of 506 mothers reported, 281, 55.5 per 
cent, had no test; 225, 44.5 per cent, had 
tests. Three were positive, 164 were nega- 
tive, and the result of the test was not re- 
ported for 58. Fifty-five were tested in the 
first trimester; four in the second; eight in 
the third; in 158 the time of the test was not 
reported. 

Data from institutions taking Wasser- 
manns as a routine procedure on all preg- 
nant women and infants have not been in- 
cluded. However, the result of their work 
is reflected in this series in so far as these 
infants came under the care of these pedia- 
tricians. 

From these figures it appears that in pri- 
vate pediatric practice the Wassermann test 
is being used as an aid to diagnosis. Syphi- 
lis was discovered in about 0.8 per cent. 
Among pregnant women Was.sermanns have 
been taken routinely by a few practitioners. 

We now come to the second phase of this 
investigation. This survey was undertaken 
in the effort to find the prevalence of syphilis 
among parturient women, and thereby link 
the problem to the major one of congenital 
syphilis. The study was set up along the 
lines adopted by Leiby, Dyer, and Turner'" 
in their survey of the Eastern Health Dis- 
trict in Baltimore. These investigators have 
shown that the study of .syphilis in the preg- 
nant woman is the best index to use in evalu- 
ating the amount of syphilis in a community. 
The sample of population produced year 
after year by pregnant women is quite repre- 
sentat